Applicant Individual Information {HS 215A}

HS 215A - APPLICANT INDIVIDUAL INFORMATION. This form is intended for any individual owning the applicant facility or for any individual involved (now or in the past) with any health or community care facility. Refer to the INSTRUCTION SHEET to see who needs to complete this form. This HS 215A form needs to be completed as part of an application package plus it needs to be completed for disclosure purposes when changes are reported in officers, directors, purchase of stock, etc., as required by law, even though no change in legal ownership is occurring. www.FormsWorkflow.com