(1) Name of applicant and, if an individual, verification that the applicant has attained the age of 18 years.

(2) Type of facility to be operated and types of services for which approval is requested.

(3) The location of the intermediate care facility.

(4) Name and license number of the administrator in charge of the intermediate care facility.

(5) If the applicant is an individual, satisfactory evidence that the applicant and the person in charge of the intermediate care facility for which application for license is made are of reputable and responsible character.

(6) If applicant is a firm, association, organization, partnership, business trust, corporation or company, satisfactory evidence that the members or shareholders holding five percent or more stock, officers, any member having responsibility in the operation of the facility and the person in charge of the intermediate care facility for which application for license is made are of reputable and responsible character.

(7) If the applicant is a political subdivision of the State or other government agency, satisfactory evidence that the person in charge of the intermediate care facility, for which application for license is made, is of reputable and responsible character.

(8) The name, title, principal business address and the percentage of ownership interest of all officers, directors and stockholders having a beneficial interest of 10 percent or more in the applicant corporation or partnership. If any such person has served or currently serves as an administrator, general partner, or corporate officer or director of, or has held a beneficial ownership interest of 10 percent or more in any other skilled nursing facility or intermediate care facility, or in any community care facility licensed pursuant to Community Care Facility Act, Chapter 3 (commencing with Section 1500) of the Health and Safety Code, the applicant shall disclose to the Department the person's relationship to the facility, including the name and current or last address of the health facility or community care facility and the date such relationship commenced, and if applicable, the date it was terminated. Each such person shall also disclose whether he or she was an officer, director, general partner or owner of a 10 percent or greater interest in a licensee of a skilled nursing facility, intermediate care facility or community care facility at a time when one or more violations of law were committed therein which resulted in suspension or revocation of its license.

(9) Copy of the current organizational chart.

(10) Certificate of Need or a Certificate of Exemption from the Department if required by Chapter 1, Division 7 of this title.

(11) Such other information or documents (such as fingerprint cards and qualification information forms) as may be required by the Department for the proper administration and enforcement of the licensing statutes and regulations.