California Code of Regulations
Title 22 - Social Security
Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
Chapter 5 - Referral Services
Article 2 - License
Section 74105 - Content of Application for License

(1) Name of applicant, and if an individual, whether the applicant has attained the age of 18 years.

(2) Name of referral agency.

(3) The location of the referral agency.

(4) The business or occupation engaged in by each applicant, and by each partner, officer and director, for at least two years immediately preceding the filing of the application. In addition, each such person shall submit a statement setting forth whether he has previously engaged in the operation of a referral agency, whether he has been involved in, or the subject of, a refusal or revocation of a referral agency license, and whether he has been convicted of a crime other than a minor traffic offense.

(5) If the applicant is a corporation, the name and principal business address of each officer and director of the corporation; and for nonpublic corporations, the name and business address of each stockholder owning ten percent or more of the stock and the name and business address of any corporation member who has responsibility in the operation of the facility.

(6) If the applicant is a partnership, the name and principal business address of each partner.

(7) Evidence of the right to occupy the premises where the referral agency is to be located.

(8) A copy of the partnership agreement or the Articles of Incorporation, if applicable.

(9) A copy of the current organization chart.

(10) A schedule of fees to be charged and collected by the referral agency, and a statement of the method by which each fee is to be computed or determined.

(11) A declaration that neither the licensee nor any member of the partnership or corporation will have any financial interest in any health facility doing business with the referral agency.

(12) Such other information or documents as may be required by the Department for the proper administration and enforcement of the licensing law and requirements.