Completing Your Timesheet - California Department of ...

STATEMENT ACKNOWLEDGING REQUIREMENT …

LIC 9108 (3/05) PAGE 2 OF 2 SIGNATURE DATE WHERE TO CALL IN AND SEND THE WRITTEN ABUSE REPORT Reports of suspected child abuse or neglect must be made to any police department or sheriff's

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IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM …

in-home supportive services (ihss) program health care certification form note: the ihss worker may contact you for additional information or to

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IMPORTANT INFORMATION FOR PROSPECTIVE …

state of california - health and human services agency california department of social services important information for prospective providers about the

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Important Information for the In-Home …

TEMP 3001 (11/15) PAGE 1 of 7 STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES Important Information for the

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LICENSE APPLICATION AND INSTRUCTIONS FOR …

LICENSE APPLICATION AND INSTRUCTIONS FOR FAMILY CHILD CARE HOMES This contains instructions needed to file an application for a Family Child Care Home license, and to gain access to

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REQUEST FOR LIVE SCAN SERVICE - COMMUNITY …

guidelines for community care licensing (ccld) applicants who use a live scan site (ccld ordoj site) for fingerprinting instructions for the lic 9163

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STATE OF CALIFORNIA - HEALTH AND HUMAN …

state of california - health and human services agency california department of social services community care licensing division lic 9214 (6/16) page 2 of 2

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STATE OF CALIFORNIA – HEALTH AND HUMAN …

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES . APPLICATION FOR SOCIAL SERVICES . To the Applicant: All sections of this form must be completed.

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STATEMENT ACKNOWLEDGING REQUIREMENT …

soc 341a (3/15) statement acknowledging requirement to report suspected abuse of dependent adults and elders name position facility note: retain in employee/ volunteer file

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STATE OF CALIFORNIA – HEALTH AND HUMAN …

REPORT OF SUSPECTED DEPENDENT ADULT/ELDER FINANCIAL ABUSE FINANCIAL INSTITUTIONS ONLY GENERAL INSTRUCTIONS PURPOSE OF THE FORM This form is to be used by officers and employees of financial institutions (“mandated reporter(s)”) to report suspected

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USE BLACK OR BLUE INK ONLY TRANSACTION TYPE • FOR …

black (check one) brown blue green hazel gray dichromatic black brown blonde red gray white bald ... use black or blue ink only are you a u.s. citizen? renew duplicate out-of-state update _____ ... signature on the form will only be accepted if notarized. court papers or appropriate documentation must be presented to the dmv

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then follow step 11 to continue ink charging Start Here

fill or refill the ink tanks, as ink may splatter. If ink spills, wipe it off immediately with a damp towel to avoid permanent stains. If ink gets on your clothes or belongings, it may not come off. Caution: Keep the ink bottles out of the reach of children and do not drink the ink. 1 Open the ink tank unit cover, then remove the cap for the

2 2 Unpack the black (BK) ink bottle. Hold the ink bottle ...

5 When the ink tank is full, remove the ink bottle and securely close it with the bottle cap. If any ink remains in the bottle, close the bottle and store it for later use. Note: Do not leave the ink bottle inserted; otherwise the bottle may be damaged or ink may leak. 6 Securely close the black ink tank cap. Start Here ET-2800/ET-2803

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Use Black or Blue Ink to Complete This Application ...

4. Is this business location only open during a portion of a calendar year? Yes No If yes, provide the: First calendar month this business location is open: ; and the Last calendar month this business location is open: . 5. Form of Business Ownership: (select only one form of ownership)

  Only, Black

BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT

REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process ... See Black Lung and FECA instructions regarding required procedure and diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, …

  Only, Black