For / The Agency for Health Care Administration / Agency for Persons / State Limited Liability Company / Standard Limited / Agency for Health Care Administration Case / Profit Public Corporation Corporation / /
Currency
USD / /
Event
Product Recall / Business Partnership / Name Change / Product Issues / /
Facility
Facility Name Change Other / /
IndustryTerm
liability insurance coverage / bank statements / ownership applications / sanitation/food hygiene / requested information / /
Organization
Department of State / Limited Nursing Service / Department of Financial Services / Department of Children and Family / Assisted Living Center / Dept of Health / State Division of Corporations / officers of Management Company If / Licensee AUTHORITY / officers of Licensee If / officers of Licensee TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER / officers of Management Company TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER / Municipal Government / Agency’s Background Screening Unit / Department of Children and Families / Department of Health / Division of Corporations / Long Term Care Unit / Medicare / /
Person
Pay Beds / Payee / /
Position
Chief Financial Officer / attorney / board member / State Fire Marshall / administrator / Administrator /Director and Chief Financial Officer / OWNERSHIP INTEREST Director/CEO President Vice President Secretary Treasurer / authorized representative / representative / facility representative / attorney for any ALF residents / General / Administrator /Director / officer / Florida Secretary / State Fire Marshal / /
Product
Form 3110-1024 / INCREASE/DECREASE / application / /
Applicants must include the following attachments as stated in Chapters 408, Part II, and Chapter 429, Florida Statutes (F.S.), and Chapters 59A-35 and 58A-5, Florida Administrative Code (F.A.C.). Applications must be