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Application To Report Change Of Corporate Title For Current Officer 13A-7a - California
| Application To Report Change Of Corporate Title For Current Officer Form. This is a California form and can be used in Contractors State License Board Statewide . |
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FOR C CSLB USE ON NLY CONTR RACTORS STA ATE LICENSE BOARD E STATE OF CALIFORNIA F 9821 Bus siness Park Drive Sacramento, CA 95827 e, C G Governor Edmun G. Brown Jr. nd Mailing Ad ddress: P.O. Bo 26000, Sacram ox mento, CA 95826 800-321-C CSLB (2752) | www.cslb.ca.gov | CheckTheLic w v censeFirst.com Application to Report Change of Corpora Title for A n t o ate r Current Officer of a Corpo o oration No Fee o Use this applicatio only to cha on ange the title of a current officer already on record. o o y U one form for each office title change Each additional officer mus use a separa form. Use f er e. st ate If you have add f ditional licenses with the same corporate reg s e gistration numb you must s ber, submit a copy o this form for each license. of A licenses usin the same co All ng orporate numbe must show the same corpo er t orate officers. T add a new officer to a corp To o poration, use fo 13A-7 Application to Add New Officer to a Corporation orm o n. T disassociate an officer, inc To e cluding a responsible managin officer (RMO or responsib managing e ng O) ble employee (RME use form E), 1 13M-5, Disasso ociation Request. T replace a cu To urrent RMO or RME, use form 13A-2a, Appli m ication for Rep placing the Qua alifying Individu ual. Please type or print legibly in black or blue ink. SEC CTION 1 BUS SINESS NAME AND ADDRESS E Plea provide the fu legal business name as it appe ase ull s ears on the license. P. O. Boxes and private maill boxes (PMB) ar not acceptable for the street re ress. addr 1. FULL BUSINESS NA AME 2. CSLB LICENSE NU C UMBER 3. CORPORAT REGISTRATIO NUMBER TE ON 4. BUSINESS MAILING ADDRESS Number/Street or P. O. Box G O 5. BUSINESS STREET ADDRESS Num T mber/Street Only No P.O. Boxes or PMBs r 6. BUSINESS PHONE NUMBER E City City State State ZIP Code ZIP Co ode BUSINESS FAX NUMBER BUSINESS E-MAI ADDRESS IL ( ) ( ) SEC CTION 2 OFF FICER'S FULL LEGAL NAME ADDRESS, AND NEW CO RPORATE TIT E, A TLE Plea provide the fu legal name of the officer. If the individual does not have a mid ase ull o s ddle name, write "None" or "No M Middle Name" in the space n Initial Only)" afte r the initial. provided. If the individual has only an initial for his or her first or middle name, write "(I DATE OF BIR RTH SOCIAL S SECURITY NUMBE ER HOME PHO ONE NUMBER 7. O OFFICER'S FULL LEGAL NAME La ast First Middle ( 8. C CURRENT CORPORATE TITLE ) NEW CORPOR RATE TITLE May not be an RMO o RME (see above) y or I cert under penalty of perjury unde the laws of the State of Californ that all statem rtify y er e nia ments, answers, and representat tions made in this application, s inclu uding all supplem mentary statemen attached here are true and accurate, and th I have review the entire con nts eto, hat wed ntents of this app plication. (The defin nition of "perjury" is telling a lie wh under oath.) I authorize the Franchise Tax Bo " hile F oard to provide C CSLB with requir tax informatio pursuant to red on Business and Profes ssions (B&P) Cod Section 7145.5. de Date e Sig gnature of Corpo orate Officer Printed Name of Corpor rate Officer COLL LECTION OF SO OCIAL SECURITY NUMBERS Y With th exception of the driver license numbers, all information requested on the application is man he e ndatory, including d disclosure of U.S. S Social Security num mbers (SSN). Collect tion of the SSN is authorized by B&P Code Section 30 and Public Law 94-4 (42 U.S.C.A. 4 a 455 405(c)(2)(C)). SSNs are used exclusiv s vely for the purpose of tax enforcemen e nt and/or compliance with an judgment or order for family suppo in accordance with Family Code Se ny ort w ection 17520. If you fail to disclose yo SSN, you will be reported to the u our e Franch hise Tax Board, and they may assess a $100 penalty aga d ainst you. The offic responsible for the maintenance o this information is the Registrar of C cial of s Contractors, Contractors State License Board. The inform e mation may be trans sferred to other sta or government a ate agencies. Individua have the right to review files or rec als o cords about them maintained by the agency unless the record are identified as confidential inform y, ds mation and exempte from the Informa ed ation Practices Act, Civil Code Section 1798.3. , n COLL LECTION OF PERSONAL INFOR RMATION CSLB c collects the personal information requ uested on this form as authorized by B&P Code Section 30 and California C B Code of Regulation (CCR) Section 8 ns 816. CSLB uses this s informa ation to identify and evaluate applican for licensure, iss and renew licen d nts sue nses, and enforce licensing standards set by law and re s egulation. Submissi of the requested ion informa ation is mandatory. CSLB cannot cons sider your applicati for licensure or renewal unless yo provide all of the requested informa ion ou e ation. You may revi iew the records maintained by CSLB that contain your perso onal information, as permitted by the Information Practice Act. CSLB make every effort to p s es es protect the personal information you e ay lic quest as allowed by the Information Practices Act; to ano y other government a agency as required by provide us; however, it ma be disclosed in response to a Publ Records Act req state or federal law; or in response to a cour or administrative order, a subpoena or a search warra The application contains an applic rt a, ant. n cant authorization f the Franchise Tax for T Board t disclose to CSLB any outstanding final liabilities for th purpose of administering B&P Cod e Section 7145.5. For more information on the Information Practices Act, visit to B f he v the Off fice of Privacy Prote ection's website at www.privacy.ca.go or call (866) 785 ov, 5-9663. FOR C CSLB USE ONLY *c chng-o off-title* * 13A-7a (05/2012) Application Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
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