Disassociation Request {13m-5}

13M-5, Disassociation Request, Use this form to notify CSLB of the disassociation of a General Partner, Qualifying Partner, Officer, Responsible Managing Officer (RMO), or Responsible Managing Employee (RME). This notice must be received at CSLB Headquarters within 90 days after the effective date of the disassociation. If the notice is received after 90 days, the date CSLB receives it will be used as the disassociation date. This may result in the suspension or cancellation of the license or the removal of a classification from the license, effective that date. (See Business and Professions Code Sections 7076, 7068.2 and 7083.) www.FormsWorkflow.com