GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Required Forms to be Licensed:
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Licensure & Certification Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Applicant Individual Information
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
15a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Administrative Organization
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
09.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Transmittal Application for Criminal Background 
Investigation
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h322.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Criminal Record Clearance Submissions
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h325.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Affidavit Regarding Patient Money
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs4
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Surety Bond Verification
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs4
02.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Transfer Agreement Between
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs6
02.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Civil Rights Compliance Review
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/dhc
s1051.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Request for Live Scan Service
http://ag.ca.gov/fingerprints/forms/BCIA_8016.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Required Forms to be Certified with Medicaid/Medi-Cal:
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Notice - Effective Date of Provider Agreement
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
28.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Medi-Cal Provider Agreement
http://files.medi-cal.ca.gov/pubsdoco/Publications/masters-
other/provappsenroll/21enrollment_DHCS9098.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Intermediate Care Facilities for Persons with Mental 
Retardation Survey Report
http://www.cms.hhs.gov/cmsforms/downloads/CMS3070G
.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Management Company - Hospital
Licensure & Certification Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Applicant Individual Information
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
15a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Administrative Organization
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
09.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Additional Documentation
http://www.cdph.ca.gov/pubsforms/forms/Documents/Ma
nagementCoAppRequestLtrChecklist-Hosp.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Management Company - Skilled Nursing Facility or 
Intermediate Care Facility
Licensure & Certification Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Applicant Individual Information
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
15a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Administrative Organization
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
09.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Additional Documentation
http://www.cdph.ca.gov/pubsforms/forms/Documents/Ma
nagementCoAppRequestLtrChecklist.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Primary Care Clinics
Primary Care Clinic - Community or Free Clinic (Including 
Mobile Clinic)
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Licensure & Certificaiton Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Certification Form for Clinics and Freestanding 
Outpatient Clinic Services of a Hospital
Title 24 Building Requirements: In lieu of a letter from a 
licensed architect, the licensed architect may use the 
attached form
http://www.cdph.ca.gov/pubsforms/forms/Documents/Cli
nicsCertificationForm.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Last Updated 4/24/2014
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GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Applicant Individual Information
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
15a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Administrative Organization
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
09.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Transfer Agreement Between
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs6
02.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Fire Safety Inspection Request
http://www.documents.dgs.ca.gov/osp/pdf/std850.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Civil Rights Compliance Review
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/dhc
s1051.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Required Forms to be Certified with Medicaid/Medi-Cal:
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Application for Medi-Cal Certification as a Primary 
Care Clinic Provider
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
69.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Notice - Effective Date of Provider Agreement
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
28.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Medi-Cal Provider Agreement
http://files.medi-cal.ca.gov/pubsdoco/Publications/masters-
other/provappsenroll/21enrollment_DHCS9098.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Rural Health Clinics (Non-Urbanized Area)
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Designation Determinant Forms
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Medically Underserved or Health Professional 
Shortage Areas
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs6
10.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Request to Establish Eligibility
http://www.cms.gov/cmsforms/downloads/CMS29.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Required Forms to be Certified with Medicaid
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Licensure & Certification Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Applicant Individual Information
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
15a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Administrative Organization
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
09.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Notice - Effective Date of Provider Agreement
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
28.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Medi-Cal Provider Agreement
http://files.medi-
cal.ca.gov/pubsdoco/provappsenroll/21enrollment_DHCS9
098.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Required forms to be Certified with Medicare:
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Licensure & Certification Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Applicant Individual Information
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
15a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Administrative Organization
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
09.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Notice - Effective Date of Provider Agreement
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
28.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Medicare General Enrollment Health Care 
Provider/Supplier Application
http://www.cms.hhs.gov/cmsforms/downloads/cms855a.p
df
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Health Insurance benefit Agreement
http://www.cms.gov/cmsforms/downloads/cms1561a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Civil Rights Information Request for Medicare 
Certification
http://www.hhs.gov/ocr/civilrights/clearance/pregrantchec
klist.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Assurance of Compliance 
http://www.hhs.gov/ocr/civilrights/clearance/hhs690.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Required Forms if Already Licensed PCC and Want to be 
Certified with Medicaid/Medi-Cal as a RHC (Non-
Urbanized Area)
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
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GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Notice - Effective Date of Provider Agreement
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
28.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Medi-Cal Provider Agreement
http://files.medi-cal.ca.gov/pubsdoco/Publications/masters-
other/provappsenroll/21enrollment_DHCS9098.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Required Forms if Already Licensed PCC and Want to be 
Certified with Medicare as a RHC (Non-Urbanized Area)
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Notice - Effective Date of Provider Agreement
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
28.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Medicare General Enrollment Health Care 
Provider/Supplier Application
http://www.cms.hhs.gov/cmsforms/downloads/cms855a.p
df
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Health Insurance benefit Agreement
http://www.cms.gov/cmsforms/downloads/cms1561a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Civil Rights Information Request for Medicare 
Certification
http://www.hhs.gov/ocr/civilrights/clearance/hhs690.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Assurance of Compliance 
http://www.hhs.gov/ocr/civilrights/clearance/hhs690.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnn
ualReport2013.pdf
Skilled Nursing Facilities or Intermediate Care Facilities
Required Forms to be Licensed:
Licensure & Certification Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Applicant Individual Information
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs2
15a.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Administrative Organization
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
09.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Affidavit Regarding Patient Money
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs4
00.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Surety Bond Verification
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs4
02.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Transfer Agreement Between
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs6
02.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Bed or Service Request
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h609.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Civil Rights Compliance Review
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/dhc
s1051.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Nursign Facility or Intermediate Care Facility Required 
Forms to be Certified with Medicaid/Medi-Cal
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Notice - Effective Date of Provider Agreement
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
28.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Medi-Cal Provider Agreement
http://files.medi-cal.ca.gov/pubsdoco/Publications/masters-
other/provappsenroll/21enrollment_DHCS9098.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Skilled Nursing Facilities Required Forms to be Certified 
with Medicare
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Notice - Effective Date of Provider Agreement
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/hs3
28.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Long Term Care Facility Application for Medicare and 
medicaid
http://www.cms.hhs.gov/cmsforms/downloads/cms671.pd
f
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Medicare Enrollment Application
http://www.cms.hhs.gov/cmsforms/downloads/cms855a.p
df
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Health Insurance benefit Agreement
http://www.cms.hhs.gov/cmsforms/downloads/cms1561.p
df
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Civil Rights Information Request for Medicare 
Certification
http://www.hhs.gov/ocr/civilrights/clearance/pregrantchec
klist.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Assurance of Compliance 
http://www.hhs.gov/ocr/civilrights/clearance/hhs690.pdf
http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertFeeL
isting13.pdf
Last Updated 4/24/2014
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GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Drinking Water and Environmental Management
Generator Registration Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8550.pdf
Free
Application for Water Treatment Operator Examination, 
Re-Examination, or Examination for Restricted Certificate
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8629.pdf
Fee printed on form
Application for Water Distribution Operator Examination, 
Re-Examination, or Examination for Restricted Certificate
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8631.pdf
Fee printed on form
Home Generated Sharps Consolidation Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8663.pdf
Free
Medical Waste Facility Permit Checklist
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8667.pdf
Fee printed on form
Medical Waste Transporter Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8668.pdf
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph8667.pdf
Small Quantity Generator With Onsite Treatment Permit 
Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8705.pdf
Fee printed on form
Large Quantity Generator With Onsite Treatment Permit 
Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8706.pdf
Fee printed on form
Current Fees (California Medical Waste Management 
Program)
Free
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph8662.pdf
Genetic Disease Screening Program
Genetic Counselor License Application
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h4486.pdf
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph4487.pdf
Genetic Counselor Licensure Continuing Education 
Declaration
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h4488.pdf
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph4487.pdf
Food, Drug, and Radiation Safety
http://www.cdph.ca.gov/pubsforms/forms/Pages/FoodDru
gandRadiationSafety.aspx
Food & Drug Branch
New Drug Manufacturing Licensce Application (CDPH 52 
N)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h52N.pdf
Fee printed on form
Biennial Drug Manufacturing License Renewal Application 
(CDPH 52 R)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h52R.pdf
Fee printed on form
Disclosure Statement - Human Prescription Drug 
Manufacture (CDPH 53)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h53.pdf
Fee printed on form
New Medical Device Manufacturing License Application 
(CDPH 72 N)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h72N.pdf
Fee printed on form
Biennial Medical Device Manufacturing License 
Application (CDPH 72 R) 
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h72R.pdf
Fee printed on form
Export Document Application (CDPH 8582)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8582.pdf
Fee printed on form
Bottled Water Distributor License Application (CDPH 
8590)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8590.pdf
Fee printed on form
Cold Storage or Refrigeration Facility License Application 
(CDPH 8591)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8591.pdf
Fee printed on form
Frozen Food Locker Plant License Application (CDPH 
8592)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8592.pdf
Fee printed on form
Organic Processed Product Registration Application 
(CDPH 8593)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8593.pdf
Fee printed on form
Private Water Source Operator License Application (CDPH 
8594)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8594.pdf
Fee printed on form
Cannery License Application (CDPH 8597)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8597.pdf
Fee printed on form
Retail Food Program Service Request Application (CDPH 
8601)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8601.pdf
Fee printed on form
Retail Water Facility License Application (CDPH 8602)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8602.pdf
Fee printed on form
drinking, water, environment, tap, treatment, waste, 
medical, 
genetic, disease, screening, counselor,
Last Updated 4/24/2014
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GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Water Bottling Plant License Application (In-State or Out-
of-State Bottler) [CDPH 8603]
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8603.pdf
Fee printed on form
Water Vending machine Operator License Application 
(CDPH 8604)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8604.pdf
Fee printed on form
Water Hauler's License Application (CDPH 8605)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8605.pdf
Fee printed on form
Shelfish Handling and Marketing Certificate Application 
(CDPH 8642)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8642.pdf
Fee printed on form
Commodity Codes (CDPH 8675)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8675.pdf
Fee printed on form
Pet Food Processor License/Registration Application 
(CDPH 8676)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8676.pdf
Fee printed on form
Cosmetic Manufacturing Registration Application (CDPH 
8678)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8678.pdf
Fee printed on form
Home Medical Device Retailer License Application (CDPH 
8679)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8679.pdf
Fee printed on form
Out-of-State Home Medical Device Retailer Registration 
Application (CDPH 8679 O)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8679O.pdf
Fee printed on form
Food Safety Fee Exemption Request (CDPH 8694)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8694.pdf
Free
Application for Home Medical Device Retailer Exemptee 
License - New and Renewal (CDPH 8695)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8695.pdf
Fee printed on form
License/Registration Verification Request (CDPH 8707)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8707.pdf
Fee printed on form
Food and Drug Laboratory
Application for Forensic Alcohol Laboratory, Page A 
(CDPH 8671)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8671.pdf
Free
Demonstration of Qualifications of a Person Employed in 
Forensic Alcohol Analysis, Page B (CDPH 8672)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8672.pdf
Free
Application Form, Forensic and Breath Alcohol Analyses, 
Page C (CDPH 8673)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8673.pdf
Free
Report of Change Form (CDPH 8674)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8674.pdf
Free
Radiology Health Branch
Certification and Schools (Healing Arts)
Radiological Technologist (RT) Forms
Radiologic Technology Certificate Application 
(CDPH 8200)
Diagnostic and Therapeutic - DO NOT use for renewal
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8200.pdf
Fee printed on form
Mammographic Radiologic Technology Certificate 
Application (CDPH8200 M)
DO NOT use for renewal
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8200m.pdf
Fee printed on form
Fluoroscopy Permit Application (CDPH 8218)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8218.pdf
Fee printed on form
Special Renewal Application for Certified Radiologic 
Technologists (CDPH 8200 SRA)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8200sra.pdf
Fee printed on form
Licentiate Forms (i.e., MD, DO, DC, DPM)
California Licentiate Supervisor and Operator 
Permit (CDPH 8230)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8230.pdf
Fee printed on form
California Radiology Supervisor and Operator 
Certificate (CDPH 8231)
For Radiologists ONLY/DO NOT USE FOR CERTIFICATE 
RENEWAL
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8231.pdf
Fee printed on form
Special Renewal Application--California Supervisor 
and Operator Certificate or Permit (CDPH 8238)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8238sra.pdf
Fee printed on form
California Licentiate X-ray Bone Densitometry 
Supervisor and Operator Permit (CDPH 8711)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8711.pdf
Free
Limited Permit X-ray Technician (XT) Forms
Limited PermitX-Ray Technician Application (CDPH 
8232)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8232.pdf
Fee printed on form
safety, food, drug, radiation, medical, bottled, water, 
cannery, frozen, plant, vending, shelfish, retail, organic, pet, 
cosmetic, forensic, alcohol, breath, 
Last Updated 4/24/2014
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GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Limited Permit X-Ray Technician Bone 
Densitometry Permit Application (CDPH 8232 BD)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8232bd.pdf
Fee printed on form
Special Renewal Application - Limited Permit X-Ray 
Technician (CDPH 8232 SRA)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8232sra.pdf
Fee printed on form
Limited Permit X-Ray Technician Digital 
Authorization Application (CDPH 9054)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h9054.pdf
Free
Special Renewal Application - Limited Permit X-Ray 
Technician - Bone Densitometry (CDPH 8232 BD 
SRA)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8232bdsra.pdf
Fee printed on form
Nuclear Medicine Technologist Forms
Nuclear Medicine Technology Certificate 
Application (CDPH 8435)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8435.pdf
Fee printed on form
Special Renewal Application Form for Certified 
Technologist, Nuclear Medicine only (CDPH 8435 
SRA)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8435sra.pdf
Fee printed on form
Change of Address Form - RT, XT, NMT, and Licentiate
Report of Name or Address Change: RT, XT, NMT, 
and Licentiates (CDPH 8391)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8391.pdf
Free
Accommodation Request - RT, XT, NMT, & Licentiate
Accommodation Request (CDPH 8625)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8625.pdf
Free
School Forms (RT and XT)
Report of Change in Information for Approved 
Schools (CDPH 8697)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8697.pdf
Free
Limited Permit XT School Affiliated Clinical Site 
(CDPH 9053)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h9053.pdf
Free
RT School Affiliated Clinical Site (CDPH 9092)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h9092.pdf
Free
General Licensing Forms
Radioactive Material License Application (Non-
medical) (RH 2050)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/rh2
050.pdf
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/RHB-
RML-Fees.pdf
Statement of Training and Experience (Non-
medical) (RH 2050A)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/rh2
050a.pdf
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/RHB-
RML-Fees.pdf
General License Device Registration Form
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8240.pdf
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/RHB-
RML-Fees.pdf
Medical Use
Radioactive Material License Application (RH 2000)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/rh2
000.pdf
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/RHB-
RML-Fees.pdf
Termination
Certificate of Disposition of Materials (CDPH 5314)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h5314.pdf
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/RHB-
RML-Fees.pdf
Miscellaneous Forms
Notice to Employees (RHB 2364 [5/09])
Fee
Radiation Machine (X-Ray) Registration
Radiation Machine Registration
PLEASE SEND FORM TO: California Department of Public 
Health - Radiologic Health Branch, MS 7610, Registration 
Unit P.O. Box 997414 Sacramento, CA 95899-7414
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/rh2
261.pdf
Free
Application for Mammography Facility/Machine 
Certification
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h8623.pdf
Free
Maternal and Child Health
Application for Certification as a Comprehensive Perinatal 
Services Program (CPSP) Provider
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h4448.pdf
Free
Lead Poisoning
Application for Participation in the California Blood Lead 
Proficiency Assurance Program
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab
608.pdf
Free
maternal, child, health, cpsp, perinatal
lead, poisoning, blood
Last Updated 4/24/2014
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GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Certification of Nurse Assistant (CNA), Home Health Aide 
(HHA) and Hemodialysis Technician (CHT).
To ensure compliance with state and federal regulations 
to be certified in the State of California.
http://www.cdph.ca.gov/pubsforms/forms/Pages/CNA_HH
A_HemoTechForms.aspx
Free
Request for Live Scan Service (BCIA 8016)
http://www.cdph.ca.gov/pubsforms/forms/Documents/CN
A-LiveScanFormBCIA8016.pdf
Free
40 Hour Home Health Aide (HHA) Training Program 
Application (CDPH 171)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h171.pdf
Free
40 Hour Home Health Aide (HHA) Training Program 
Faculty Application (CDPH171B)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h171b.pdf
Free
120 Hour Home Health Aide (HHA) Training Program 
Application (CDPH 191)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h191.pdf
Free
Application for Initial or Renewal Approval as a 
Continuing Education Provider (CDPH 192)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h192.pdf
Free
Application for Initial or Renewal Online Continuing 
Education Provider (CDPH 192B)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h192b.pdf
Free
Nurse Assistant Training Program Individual Student 
Record (CDPH 276 C)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h276c.pdf
Free
Disclosure of Ownership and Control Interest Statement 
(CDPH 276 D)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h276d.pdf
Free
Skilled Nursing Facility (SNF) Nurse Assistant Certification 
Training Program Application (CDPH 276F)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h276f.pdf
Free
School Nurse Assistant Certification Training Program 
Application (CDPH 276 S)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h276s.pdf
Free
In-Service Training Program (CDPH 278 B)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h278b.pdf
Free
Director of Staff Development/Instructor Application 
(CDPH 279)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h279.pdf
Free
Certified Nurse Assistant In-Service Training/Continuing 
Education (CDPH 283 A)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/CD
PH283a.pdf
Free
Certified Nurse Assistant And/Or Home Health Aide Initial 
Application (CDPH 283 B)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h283b.pdf
Free
Certified Nurse Assistant And/Or Home Health Aide 
Renewal Application (CDPH 283 C)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/CD
PH283c.pdf
Free
Certified Hemodialysis Technician Initial Application 
(CDPH 283 F)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h283f.pdf
Free
Certified Hemodialysis Technician Renewal Application 
(CDPH 283 G)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h283g.pdf
Free
Transmittal for Criminal Background Clearance (CDPH 283 
I)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h283i.pdf
Free
Hemodialysis Technician/Patient Care Technician Training 
Program Application (CDPH 391)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/CD
PH%20391.pdf
Free
Request for Name/Address Change And/Or Duplicate for 
CAN/HHA/CHT Certificate (CDPH 929)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h0929.pdf
Free
Verification of Current Nurse Assistant Certification 
(CDPH 931)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h931.pdf
Free
Program Flexibility (CDPH 5000)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h5000.pdf
Free
Licensure of Nursing Home Administrators
To ensure compliance with state and federal regulation 
to be licensed in the State of California.
http://www.cdph.ca.gov/pubsforms/forms/Pages/Nursing
HomeAdministrator.aspx
http://www.cdph.ca.gov/certlic/occupations/Documents/13_14%20N
HAP%20Fee%20List.pdf
Admintrator in Training (AIT) Evaluation Report (CDPH 
501)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h501.pdf
Free
Application for AIT Program (CDPH 502)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h502.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Application for AIT Program Instructions (CDPH 502 
Instructions)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h502Instructions.pdf
Free
Application for Educational Waiver for AIT Program 
(CDPH 502 A)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h502a.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
nurse, cna, hha, cht, hemodialysis
Last Updated 4/24/2014
GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Application for Nursing Home Administrator State 
Examination (CDPH 503)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h503.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Application for Nursing Home Adminstrator State 
Examination (CDPH 505)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h505.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Application for Nursing Home Adminstrator License 
(CDPH 506)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h506.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Application to Become a Provider of Continuing Education 
(CDPH 508)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h508.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Continuing Education Courses Completed for Active 
License Renewal (CDPH 509)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h509.pdf
Free
Declaration and Request for Replacement License (CDPH 
510)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h510.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Instructor Application for C. E. Credit (CDPH 511)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h511.pdf
Free
License Renewal Affidavit for Nursing Home 
Adminstrators (CDPH 512)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h512.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Licensee's Request for Course Approval (CDPH 513)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h513.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
NHA/Facility Profile Sheet (CDPH 514)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h514.pdf
Free
Preceptor Continuing Education Credit Application (CDPH 
515)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h515.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Preceptor Training Registration Form (CDPH 516)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h516.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Provider Request for Course Approval (CDPH 518)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h518.pdf
Free
Provider Request for Course Renewal (CDPH 519)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h519.pdf
Free
Request for Provider Renewal (CDPH 522)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h522.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Special Accommodation Request for Examination (CDPH 
523)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h523.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Master's or Reciprocity Application for Nursing Home 
Administrator Examination (CDPH 524)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h524.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Application for provisional License (CDPH 525)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h525.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
AIT Program Application for Re-Training (CDPH 526)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdp
h526.pdf
http://www.cdph.ca.gov/certlic/occupations/Pages/NursingHomeAd
ministrator.aspx
Request for Live Scan Service form (BCIA 8016)
http://www.cdph.ca.gov/pubsforms/forms/Documents/NH
A-LiveScanFormBCIA8016.pdf
Free
Laboratory Central Services
Application for Approval to Keep and Use Laboratory 
Animals
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab139.pdf
Free
Laboratory Field Services
Clinical Laboratory License
Licensing of clinical laboratory facilities
http://www.cdph.ca.gov/programs/lfs/Pages/ClinicalLaboratoryFacilities.aspx
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Laboratory Registration
Registration for waived/PPMP facilities
http://www.cdph.ca.gov/programs/lfs/Documents/F-Registration-Instructions.pdf
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Lab Scientist Trainee License
Licensing of trainee scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Medical Laboratory Technician
Licensing of medical technicians
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Limited Certified Phlebotomy Technician 
Licensing of limited phlebotomy technician
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Certified Phlebotomy Technician I
Licensing of phlebotomy technician I
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Certified Phlebotomy Technician II
Licensing of phlebotomy Technician II
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Laboratory Scientist
Licensing of clinical laboratory scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Chemist Scientist
Licensing of limited chemist scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Immunohematologist Scientist
Licensing of limited immunohematology scienti
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Microbiologist Scientist
Licensing of limited microbiology scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Toxicologist Scientist
Licensing of limited toxicology scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
nursing, water, drug, cosmetic, medical, device, 
laboratory, animals
laboratory, clinical, medical, technician, scientist, chemist, 
phlebotomy, microbiologist, immunohematologist, 
toxicologist, cytogeneticist, genetics, molecular, 
Last Updated 4/24/2014
GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Clinical Cytogeneticist Scientist
Licensing of limited cytogenetics scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Genetics Molecular Biologist Scientist
Licensing of limited gene mole biology scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Hematology Scientist
Licensing of limited hematology scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Histocompatibility Scientist
Licensing of limited histocompatibility scientist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Cytotechnologists
Licensing of cytologist
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Laboratory Bioanalyst Director
Licensing of laboratory bioanalyst director
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Chemist Director 
Licensing of limited chemistry director
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Microbiologist Director
Licensing of limited microbiology director
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Toxicology Director
Licensing of limited toxicology director
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Histocompatibility Laboratory Director
Licensing of limited histocompatibility director
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical cytogeneticist Director
Licensing of limited cytogenetics director
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Genetic Molecular Biologist Director
Licensing of limited genetic mole biology direct
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Clinical Oral Pathologist Laboratory Director
Licensing of limited oral path lab director
https://secure.cps.ca.gov/cltreg/
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Public Health Microbiologist
Certification of public health microbiologist
http://www.cdph.ca.gov/programs/lfs/Pages/PublicHealth.aspx
Free
License For the Production of Biologics
Licensing of biologics (blood bank) facilities
http://www.cdph.ca.gov/programs/lfs/Pages/BloodBanksandBiologics.aspx
http://www.cdph.ca.gov/programs/lfs/Documents/A-License-FeeSchedules.pdf
Tissue Bank License
Licensing of tissue bank facilities
http://www.cdph.ca.gov/programs/lfs/Documents/AP0%20check-off%20list.pdf
http://www.cdph.ca.gov/programs/lfs/Documents/AP0%20check-off%20list.pdf
Biologics License Application (LAB 114)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab114.pdf
Laboratory Personnel Report (LAB 116)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab116.pdf
Free
Laboratory Personnel Report, Out-of-State Laboratory 
(LAB 116 OS)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab116os.pdf
Free
Application for Clinical Laboratory License (LAB 144)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab144.pdf
Fee printed on form
Laboratory Testing Declaration (LAB 144 A)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab144a.pdf
Free
Application for Additional Clinical Laboratory Testing Sites-
-Form B (LAB 144 B)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab144b.pdf
Free
Application for Clinical Laboratroy License for 
Laboratories Located in States Other Than California (LAB 
144 OS)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab144os.pdf
Fee printed on form
Application--Clinical Laboratory Registration (LAB 155)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab155.pdf
Fee printed on form
Contnuing Education Waiver Request (LAB 158)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab158.pdf
Free
Complaint information (LAB 163)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab163.pdf
Free
Annual Test Volume of Test Performed (LAB 167)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab167.pdf
Free
Annual Test Volume of California Specimens-Out of State 
Laboratory (LAB 167 OS)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab167OS.pdf
Free
Tissue Bank Personnel Report (LAB 169)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab169.pdf
Free
Assisted Reproductive Technology (ART) Questionnaire 
(LAB 170)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab170.pdf
Free
Tissue Bank License--Renewal Application (LAB 171)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab171.pdf
Fee printed on form
Tissue Bank License--New Application (LAB 172)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab172.pdf
Fee printed on form
Application for Renewal of License for the Production of 
Biologics (LAB 175)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab175.pdf
Fee printed on form
Application for Duplicate License (LAB 176)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab176.pdf
Fee printed on form
Clinical Laboratory Personnel License Renewal, 
Continuing Education Activity Summary (LAB 177)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab177.pdf
Fee printed on form
Application for Continuing Education Accrediting Agency 
(LAB 178)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab178.pdf
Free
Application for Inactive Status (LAB 179)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab179.pdf
Fee printed on form
Director's Attestation (LAB 183)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab183.pdf
Free
Tissue Bank--Contact Person for Data Sheet (LAB 184)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab184.pdf
Free
Request for Facilities and/or Personnel Record (LAB 192)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab192.pdf
Free
Notification of Laboratory Change (LAB 193)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab193.pdf
Free
Disclosure of Ownership and Control Interest Statement 
(LAB 1513)
http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/lab1513.PDF
Free
Approved Public Health Laboratory
Licensing of public health microbiology facilities
http://www.cdph.ca.gov/programs/lfs/Pages/PublicHealth.aspx
Free
tissue, bank, health, animals, syringe, lrc, 
toxicologist, cytogeneticist, genetics, molecular, 
hematology, histocompatibility, oral, pathologist, health
Last Updated 4/24/2014
GO-Biz Application Forms and Fee Finder
Name of Permit, License, or Registration
Brief Description of Purpose
Application
Fee Information
Keywords
Certificate of Approval to Keep/Use Lab Animals
Approval to keep or use live, warm-blooded animals for 
education, research, testing, or diagnostic purposes
http://www.cdph.ca.gov/programs/LabAnimalUse/Documents/lab139Revised0507.pdf
Free
Public Health Vector Control Technician Exam
Examination to certify competence of government 
agency employee in the control of vectors for the health 
and safety of public.
http://www.cdph.ca.gov/certlic/occupations/Documents/V
CTExamApp.pdf
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?la
wCode=HSC&sectionNum=106925. 
Permit to Import Specified Wild Animals Into California
Importers of specified nonhuman primates, carnivores, 
and bats into California are required to obtain permit 
prior to entry.
http://www.cdph.ca.gov/programs/vphs/Documents/Wild
%20Animal%20Importation%20Application.pdf
Fee printed on form
Syringe Exchange Program Certification
The Syringe Exchange Certification Program authorizes 
qualified entities to provide syringe exchange services.
http://www.cdph.ca.gov/programs/aids/Pages/SyringeExch
angeCertificationProgram.aspx
Free
LRC Certification
Certification of individuals for lead abatement or 
inspection
http://cdph.ca.gov/programs/CLPPB/Documents/CertAppPacket.pdf
http://cdph.ca.gov/programs/CLPPB/Pages/LRCCertProcess.aspx
LRC Certification Renewal
Certification of individuals for lead abatement or 
inspection
http://cdph.ca.gov/programs/CLPPB/Documents/CertRenPacket.pdf
http://cdph.ca.gov/programs/CLPPB/Pages/LRCCertProcess.aspx
PUBLIC UTILITIES COMMISSION, CALIFORNIA
Limousine, Charter Bus and Shuttle Licensing
http://www.cpuc.ca.gov/PUC/transportation/Forms/carrierforms.htm
Fee printed on form
Household Goods Movers Licensing
http://www.cpuc.ca.gov/PUC/transportation/Forms/hhgforms.htm
Fee printed on form
REHABILITATION, DEPARTMENT OF
Limited Examination and Appointment Program (LEAP)
http://www.rehab.cahwnet.gov/LEAP/index.html
Leap Certification DR 10
Must contact a local field office to obtain certification
http://www.rehab.cahwnet.gov/DOR-Locations/index.asp
Locally Set
Vocational Rehabilitation Services Application DR-222
https://www.dor.ca.gov/Online/DR-222/Online-V-R-Services-Application.html
Free
CRP Certification & Vendorization Application DR 401
Community Rehabilitation Program
https://www.dor.ca.gov/VRED/DOR-Forms/DR0401.pdf
Free
DOR Health Care Provider
https://www.dor.ca.gov/VRED/Healthcare.html
Free
Health Care Provider Enrollment Application
https://www.dor.ca.gov/VRED/Provider-Docs/Healthcare-2012-application.pdf
Free
STD 204 Payee Data Record DR 361
https://www.dor.ca.gov/VRED/Provider-Docs/Healthcare-760-std204.pdf
Free
Business Enterprises Program
https://www.dor.ca.gov/BEP/index.html
Free
Vending Facility Permit Form
https://www.dor.ca.gov/BEP/BEP-Docs/Vending-Facility-Permit-Form-Rev-7-2-12.pdf
Free
New Location Survey
https://www.dor.ca.gov/BEP/BEP-Docs/New-Location-Survey.doc
Free
Request Placement of Vending Machines
https://www.dor.ca.gov/BEP/BEP-Docs/Request-for-the-Placement-of-Vending-Machines.doc
Free
SEP and VR/WAP Forms
https://www.dor.ca.gov/SEP/SEP-VR-WAP-Forms.html
Free
SAN FRANCISCO BAY CONSERVATION AND 
DEVELOPMENT COMMISSION
Regionwide, Administrative, or Major Permit Application 
Form
http://www.bcdc.ca.gov/media/forms/appform.pdf
http://www.bcdc.ca.gov/media/forms/app_fee_chart.pdf
Abbreviated Regionwide Permit Application Form
http://www.bcdc.ca.gov/media/forms/abbform.pdf
http://www.bcdc.ca.gov/media/forms/app_fee_chart.pdf
JARPA (Joint Aquatic Resource Permit Application)
http://www.sfestuary.com/PDF/jarpa/JARPA_final_1106.pdf
http://www.bcdc.ca.gov/media/forms/app_fee_chart.pdf
Consolidated Dredging and Dredged Material 
Reuse/Disposal Application Form
http://www.bcdc.ca.gov/media/forms/DMMO_App_Form.pdf
http://www.bcdc.ca.gov/media/forms/app_fee_chart.pdf
Certification of Contractor Review
http://www.bcdc.ca.gov/pdf/enforcement/Cert_Contractor_Rev.pdf
http://www.bcdc.ca.gov/media/forms/app_fee_chart.pdf
Notice of Completion and Declaration of Compliance
http://www.bcdc.ca.gov/pdf/enforcement/Notice_Completion_Declaration_Frm.pdf
http://www.bcdc.ca.gov/media/forms/app_fee_chart.pdf
Agreement Imposing Public Access Restrictions on the 
Use of Real Property
http://www.bcdc.ca.gov/pdf/enforcement/Public_Access_Frm-3-Revised_20130611_F.pdf
http://www.bcdc.ca.gov/media/forms/app_fee_chart.pdf
limousine, limo, charter, bus, shuttle, movers, air carriers, 
for-hire vessel carriers, private carrier, 
leap, rehabilitation, vocational
dor, health, care, rehabilitation
rehabilitation, sep, vr, wap
san, francisco, bay, development, shoreline, jarpa, bcdc
Last Updated 4/24/2014
Documents you may be interested
Documents you may be interested