Form LIC501 Personnel Record - California

Form LIC 501 Instructions

The Personnel Record (LIC 501) Form is filled out if an administrator is not the licensee. Otherwise, the same information is gathered on Form LIC 215, Applicant Information, which allows any individual to obtain a facility license.

Provide the following information on the LIC 501 Form:

1. Personal Information. Full name, address, telephone number, age, social security number, dates of the last physical examination and tuberculosis test, other names you have been employed under, driver's license number, and information. You are also required to provide details of your nearest living relative.
2. Position. State the title, salary, hours, date of employment, and the name of your supervisor.
3. Previous Employment. List the employer's name, address, and telephone number. Indicate your job title, type of work, the reason for living, and dates of employment.
4. Education. Enter the course title, name of the school, and dates of enrollment.
5. References. Name three individuals who can give information about your background, abilities, and character.
6. Professional and Technical Qualifications. List the licenses and certificates you hold and write down the names of professional associations of which you are a member.
7. Verification. Your signature and the actual date.