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State of California Health and Human Services Agency California Department of Public Health APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD PLEASE READ THE INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING
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hi I'm going to guide you through the HS 215 a applicant individual information form the applicant individual information form is used by each individual to capture their involvement now or in the past with any health or community care facility as part of the application package for licensure the provider must identify all individuals involved in their corporation limit liability company LLC or limited partnership LP etc tip this includes owners stockholders officers board members managers members administrator etc the HS 215 a form is a three-page form broken up into seven sections each section is required to be filled out and the information is used to verify compliance with CDP H health and safety code laws during this demonstration I will provide an overview of the information that's required for each section I will use the term facility when referring to a clinic or agency I will also use the term CA B moon' referring to the centralized applications branch let's begin on page 1 you will notice at the top right corner of a page 1 there is a box that stays for Department or use only please do not enter any information in this box section a is the identifying information please enter your legal first and last name nope nicknames or abbreviations this is also important please enter full date of birth tip the date of birth is used as an identifier several people have the same name this will ensure that you are associated with the correct facility and or entity the business address enter the facility or corporations address remember the HS - 15a is part of the application and the application is public record so if you use your home address it's public record title in relation to this facility enter all titles if you are the administrator the owner the treasurer etc please enter all titles next have you applied for any license for a health facility or community care facility using any name other than your true full name please enter any other names you have used to obtain a license for any other facility if an administrator for proposed clinic this is clinics only list hours that would be spent at the clinic each week if an administrator at more than one licensed clinic lists the name only the administrator of a clinic must complete this section the administrator is required to list each facility name address and hours spent at each facility per week you may use an attachment to submit your list of facilities please identify the sheet as the HS 215 a section a attachment Section B is the criminal record item one if you answer yes to the first question please explain and provide conviction information which includes the offense date of the offense if it's a misdemeanor or a felony and the disposition item two if you answer yes follow the same steps as above you may also use an attachment to submit your list of facilities please identify the sheet as HS 215 a section beat attachment Section C professional license certificates...