California Code of Regulations
Title 28 - Managed Health Care
Division 1 - The Department of Managed Health Care
Chapter 2 - Health Care Service Plans
Article 3 - Plan Applications and Amendments
Section 1300.51.1 - Individual Information Sheet

1. Name of Applicant:

___________________________

2. Exact full name of person completing this statement:

3. Physical Description:

Sex__________Hair__________Eyes__________Height__________Weight__________

___________________________

4. Birthdate: ______________________________ Birthplace: ______________________________

5. Social Security No. or

Taxpayer Ident. No: ___________________________

NOTE: The inclusion of your social security number is not required but is voluntary. It is solicited pursuant to Sections 1344 and 1351 of the Health and Safety Code. It may be used to conduct a background investigation by the Department, the California Department of Justice Information Branch, or by other federal, state or local law enforcement agencies. This form, including the social security number, will be held confidential, but is a public record and available to the public pursuant to the Public Records Act (Gov. Code Section 6250), at the discretion of the Director.

8. Current Residence Address:

9. Employment for the last 5 years (list most recent first and include any employment with a plan or any person or entity which is or was affiliated with a plan (Section 1300.45(c)):

NOTE: Attach separate schedule if space is not adequate.

10. Business contacts, dealings and affiliations (see section 1300.45(c)(2)) with health care service plans during the last 5 years (but including, for example, such roles as director, stockholder, consultant, manager, provider and supplier, and such dealings as sales, leasing, and any contractual relationships) (list most recent business contacts and dealings first):

NOTE: Attach separate schedule if space is not adequate.

11. Have you ever had a certificate, license, permit registration or exemption issued pursuant to the Business and Professions Code or Health and Safety Code denied, revoked or suspended or been otherwise subject to disciplinary action, while you were in the employ of the applicant, or while you had a contract with the applicant as a provider or otherwise?

[ ] Yes [ ] No

If "yes" state the date of the action and the administrative body taking such action.

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

12. Have you ever been convicted or pled nolo contendere to a misdemeanor involving moral turpitude or any felony, other than traffic violations?

[ ] Yes [ ] No

If the answer is "yes" give details:

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

13. Have you ever changed your name or ever been known by any name other than that herein listed? (Including a married person's prior surname, if any.)

[ ] Yes [ ] No

If so, explain. Change in name through marriage or court order should also be listed.

EXACT DATE OF EACH NAME CHANGE MUST BE LISTED.

___________________________

___________________________

14. Have you ever engaged in business under a fictitious firm name either as an individual or in the partnership or corporate form?

[ ] Yes [ ] No

If the answer is "yes" set forth particulars:

___________________________

___________________________

___________________________

___________________________

___________________________

VERIFICATION

I, the undersigned, state that I am the person named in the foregoing Individual Information Sheet, that I have read and signed said Individual Information Sheet and know the contents thereof, including all exhibits attached thereto; and that the statements made therein, including any exhibits attached thereto, are true. I certify/declare under penalty of perjury that the foregoing is true and correct.

this __________ day of ____________________.

NOTE: If this form is signed outside California complete the verification before a notary public in the space provided below.