Form LIC 9165. Board Of Director Statement - California

Form LIC 9165 is used in California for individuals seeking approval as board members for licensed facilities regulated by the California Department of Social Services. This form is completed by individuals who wish to serve as board members and provide a statement of their qualifications and commitment.

The form consists of sections that require the individual's personal information, demographics, a statement of qualifications and commitment, and space for signatures. Important fields include the individual's full name, contact information, relevant experience, educational background, and their statement outlining why they are interested in serving as a board member. It is essential to provide a comprehensive and compelling statement that demonstrates the individual's qualifications, commitment, and understanding of the responsibilities associated with being a board member.

An application example of this form would involve an individual completing Form LIC 9165 to apply for a position as a board member for a licensed facility. They would provide their personal information, outline their qualifications and commitment to the role, and sign the form. By successfully submitting this form and providing a strong statement, the individual can present themselves as a qualified candidate for the board position and contribute to the effective governance of licensed facilities in compliance with state regulations.