The following must be completed by all individuals and companies that will be listed on the license. You must provide full legal names of all individuals. Each individual must sign the certification statement under penalty of perjury. (See Section 4 of the General Information and Instructions regarding company personnel.)
This is an Easy-Fill form that will walk you through the process to fully and accurately complete this form. Upon completion, you will be required to print and submit the document to CSLB.
Be sure to use the "Back" and "Next" buttons at the bottom of each page - do not use your browser's back arrow because all of your entered information will be erased and you will have to start over.
Please type your information directly into the fields of this form. If you copy text from another application or document and paste it into this Easy-Fill form and the text contains invalid (non-ASCII) characters, they will be removed from the final document.
Make sure you give yourself enough time to complete the entire form in one sitting. You will not be able to save a partially filled form to complete at a later time.
To print or order a blank form, please click here to be redirected to CSLB's "Forms and Applications" page.