Listed below is general information to assist you as you complete the attached application. Do not submit this General Information portion with your completed application – the actual application begins immediately following this section on Application – Page 1 of 2. Before you submit your application, please review it and be sure that you have completed all requested information. Your application may be returned to you if it is insufficient or incomplete. You must provide any missing information, make corrections, and resubmit your completed application to CSLB within 90 days after the date that it was returned to you or your application will be deemed abandoned and will become void. You cannot reinstate an abandoned application – you must submit a new application and $125 application fee if you wish to reapply.
Complete the application legibly in black or dark blue ink, or on CSLB’s website using the Easy-Fill feature. Forms completed in pencil will be returned to you. Please make sure that you and other authorized individuals sign and date the application. Leave no space blank. If a particular question or request for information does not apply to you, write “N/A” in the blank space to indicate that the question has received your attention but that it is not applicable. The “#” symbol is used interchangeably with the word “number” where space is limited on the application.
Limited Liability Company (LLC) Personnel and Liability Insurance Requirement
If the existing license is an LLC, be aware that all LLC licenses are required to have liability insurance in an amount that is not less than one million dollars ($1,000,000) or more than five million dollars ($5,000,000), based on the number of personnel of record on the license. For five (5) or fewer personnel, the amount is not less than $1 million. For each additional member of the personnel, the amount increases $100,000, up to $5 million maximum. For example, an LLC that has eight (8) members of personnel would be required to carry a $1,300,000 liability insurance policy. Therefore, the additional personnel being added with this application may result in the need to increase the amount of the liability insurance. (Business and Professions Code [BPC] section 7071.19)
LLCs can have managers or members that are corporations or other LLCs, as opposed to individual people. When an LLC has corporate or LLC managers or members, complete Section 2 for those companies, omitting the fields that do not apply (e.g., date of birth, SSN/ITIN, and driver license number). Since corporations and LLCs are incapable of signing documents (e.g., applications, renewals, etc.), you must also report at least one individual person who will be an authorized responsible signer for that company. To do this, you must make a copy of Page 1 of the application after Section 1 has been completed and fill in portions of Section 2 using this individual person’s personal information. Identify that person as the “Authorized Signer for ______” (inserting the name of the corporation or LLC on behalf of which the individual person will sign). This individual person will not be part of the official license personnel of record (unless they are also an actual responsible manager, member, or officer of the LLC), but their information will be maintained by CSLB for signing purposes only.
Please be sure to read the Important Notice Regarding Convictions on the front of this application packet. All applicants for licensure are required to submit a full set of fingerprints for the purpose of conducting a criminal background check. Even though you may have been fingerprinted previously for an employer or another regulatory body, you will need to undergo the fingerprinting and criminal history check process again specifically for CSLB, unless you have previously fingerprinted for CSLB and the results are still available and active on record with CSLB. California Penal Code section 11142 prohibits criminal history information from being released to any entity other than the requesting agency that you have authorized to receive it. Individuals in California are required to fingerprint by electronic live scan; individuals outside of California can fingerprint either by electronic live scan in California or by submitting hard card fingerprints that are completed in the applicant's location, as explained in the instructions that are sent after the application has been accepted (also known as "posted"). For more information, please visit CSLB's website and view information on the Applicants page.
Collection of Social Security Numbers and Individual Taxpayer Identification Numbers
With the exception of the driver license number, all information requested on the application is mandatory, including disclosure of U.S. Social Security numbers (SSN) and individual taxpayer identification numbers (ITIN). Collection of the SSN and ITIN is authorized by BPC sections 30, 31, and 7145.5. SSNs and ITINs are used exclusively for the purpose of tax enforcement, compliance with any judgment or order for family support in accordance with Family Code section 17520, measurement of employment outcomes of students who participate in career technical education programs offered by the California Community Colleges as required by BPC section 30, and investigation of tax evasion and violations of cash-pay reporting laws as set forth in Section 329 of the Unemployment Insurance Code. If you fail to disclose your SSN or ITIN, your application will not be processed, and you will be reported to the Franchise Tax Board; they may assess a $100 penalty against you.
Collection of Personal Information
CSLB collects the personal information requested on the following form as authorized by BPC sections 30, 31, 141, 480, 7068.2, 7069, 7071, 7073, and 7145.5 and Title16 of the California Code of Regulations section 816. CSLB uses this information to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation. Submission of the requested information is mandatory. CSLB cannot consider your application unless you provide all of the requested information. You may review the records maintained by CSLB that contain your personal information, unless the records are identified as confidential information and exempted from disclosure by the Information Practices Act, including Civil Code section 1798.40. CSLB makes every effort to protect the personal information you provide us; however, it may be disclosed in response to a Public Records Act request as allowed by the Information Practices Act; to another government agency as required by state or federal law or as provided in Civil Code section 1798.24; or in response to a court or administrative order, a subpoena, or a search warrant. The Custodian of Records is responsible for maintaining the information on this form and may be contacted at the address and telephone number listed in the letterhead at the top of this General Information portion for questions about this notice or access to records.
Use this application to add NEW personnel of record to an existing corporate license (officer only) or to an existing limited liability company license (LLC) (officer, manager, or member).
Use one application for each new officer, manager, member, or director. Each additional personnel must use a separate application.
If you have additional licenses with the same corporate or LLC registration number (as issued by the California Secretary of State and listed in box 3 in Section 1), you must submit a copy of this form for each license. All licenses using the same corporate or LLC registration number must show the same officers, managers, and/or members.
To report a change of title for current personnel of record on an existing license, use form 13A-7a - Application to Report Change of Title for Current Officer or Personnel of an Existing Corporation or Limited Liability Company.
To disassociate personnel from an existing license, including a responsible managing officer (RMO), responsible managing manager, responsible managing member, director, or responsible managing employee (RME), use form 13M-5 - Disassociation Request.
To replace a current qualifying individual (RMO, responsible managing manager, responsible managing member, director, or RME) on an existing license, use form 13A-2a - Application for Replacing the Qualifying Individual.
Please provide the full legal business name as it appears on the CSLB license. P.O. Boxes and private mail boxes (PMB) are not acceptable for the street address. Also include the license number as issued by CSLB and the registration number as issued by the California Secretary of State.
* Required Entry