Section 9804 - Content of Application(a) The applicant shall submit a separate application for each site, except for satellite sites, where services are to be provided.(b) Each application for licensure shall include the following information: (1) The name of the county and DUI program in which the applicant will be providing services, and whether the applicant is applying for licensure as a first offender, 18-month, or 30-month program;(2) The legal name of the applicant and the name the DUI program will use to conduct business;(3) The telephone number and mailing address of the applicant, and the telephone number and address of the DUI program location;(4) The business status (i.e., individual owner, partnership, nonprofit or for-profit corporation, public agency, or another specified entity) under which the applicant will operate the DUI program;(5) The name(s) and address(es) of any other licensed DUI program owned or operated by the applicant(s) within the last five years;(6) The name, address, and telephone number of the program director;(7) If the applicant is a partnership, the name and principal business address of each partner, and a copy of the partnership agreement as filed with the county or state, as applicable;(8) If the applicant is a corporation or association, the name and address for the corporation or association; the name and title of the officer or employee who acts on behalf of the corporation or association; and a copy of the articles of incorporation and bylaws;(9) If the applicant is a public agency, the type of agency (i.e. county, city, or other specified), the name of the department, and address;(10) The name(s), title, education and experience of the program director in accordance with Section 9846 of this Chapter;(11) Written assurance that the DUI program will not discriminate in employment practices and in provision of benefits and services on the basis of race, color, national origin, religion, sex, or mental or physical disabilities pursuant to Title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973, California Government Code section 11135, et seq., and other applicable state and federal laws;(12) A statement, signed and dated by the applicant or the authorized representative of the applicant, declaring under penalty of perjury that all information submitted to the Department is true and correct to the best of the applicant's knowledge;(13) A signed and dated financial statement with an itemized listing of the DUI program's assets, liabilities, and equity;(14) A line item budget which includes fiscal information in the categories of personal services, operating expenses, equipment, equipment and facility depreciation schedules, revenue, and profit or surplus; and(15) The signature of the applicant as follows:(A) For partnerships, each partner shall sign the application.(B) If the applicant is a firm, association, corporation, county, city, public agency, or other governmental entity, the application shall be signed by the chief executive officer or the individual legally responsible for representing the firm, association, corporation, county, city, public agency, or other governmental entity.Cal. Code Regs. Tit. 9, § 9804
1. Change without regulatory effect amending section filed 4-15-91 pursuant to section 100, title 1, California Code of Regulations (Register 91, No. 20). For prior history, see Register 82, No. 47.
2. Amendment of section and NOTE filed 12-6-2004; operative 1-5-2005 (Register 2004, No. 50).
3. Amendment filed 3-22-2012; operative 4-21-2012 (Register 2012, No. 12). Note: Authority cited: Sections 11755, 11835, and 11836.15, Health and Safety Code. Reference: Sections 11836.12, 11836.15 and 11837.4, Health and Safety Code.
1. Change without regulatory effect amending section filed 4-15-91 pursuant to section 100, title 1, California Code of Regulations (Register 91, No. 20). For prior history, see Register 82, No. 47.
2. Amendment of section and Note filed 12-6-2004; operative 1-5-2005 (Register 2004, No. 50).
3. Amendment filed 3-22-2012; operative 4-21-2012 (Register 2012, No. 12).