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Lic9141 Form 2016
For each type of program (ARF, GH, RCFE) and vendorship (ICTP or CEU).
(1) Type of Application: (Check one box only. If renewing, provide vendor number and expiration date, and attach LIC 9139 if
renewing courses.)
■ New ■ Renewal
(2)
Vendor #________________________ Expires: ________________LIC 9139 attached?
■ YES ■ NO
Type of Program: (Check one box only; if applying for more than one, submit separate application for each.)
■ ARF (Adult Residential Facility)
■ GH (Group Home)
■ RCFE...
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