California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 4 - Certification Standards for Health Care Organizations
Section 9771.63 - Individual Information Sheet (WCHCPO 2)

2. Exact full name of person completing this statement:

3. Have you ever had a certificate, license, permit registration or exemption issued pursuant to the Business and Professions Code, Health and Safety Code, Insurance Code, or Labor 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.

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4. 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:

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___________________________

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5. 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.

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6. 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:

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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 and correct.

I certify (or declare) under penalty of perjury under the laws of the State of California that I have read this Individual Information Sheet and the exhibits thereto and know the contents thereto, and that the statements therein are true and correct.

Executed at ______________________________(Place) on ______________________________(Date)

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(Signature of Declarant)

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