§ 9771.63. Individual Information Sheet (WCHCPO 2).
8 CA ADC § 9771.63Barclays Official California Code of Regulations
8 CCR § 9771.63
§ 9771.63. Individual Information Sheet (WCHCPO 2).
An individual information sheet required pursuant to these rules shall be in the following form:
CONFIDENTIAL
DIVISION OF WORKERS' COMPENSATION
State of California
INDIVIDUAL INFORMATION SHEET
under Labor Code Section 4600.6
1. Name of Applicant: | File No.____________________ |
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.
If the answer is “yes” give details:
If so, explain. Change in name through marriage or court order should also be listed. EXACT DATE OF EACH NAME CHANGE MUST BE LISTED.
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 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)
__________________________________________________
(Signature of Declarant)
Note: If this form is signed outside California complete the verification before a notary public in the space provided below.
State of | |
County of | |
Dated, | |
at | |
(Signature of Affiant) | |
Subscribed and sworn to before me, | |
Notary Public in and for said | |
County and State |
Credits
Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.
History
1. New section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only pursuant to Stats. 1997, Ch. 346, Section 5 (Register 98, No. 16).
This database is current through 6/21/24 Register 2024, No. 25.
Cal. Admin. Code tit. 8, § 9771.63, 8 CA ADC § 9771.63
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