Page 2-6,
Part 4. Information
About the Organizational Structure, Ownership, and Control of the
Regional Center Entity
|
[Page 2]
…
List all persons or legal entities
or organizations that own or have a percentage of ownership in the
regional center entity. For persons, include each owner's name,
date of birth, country of birth, U.S. Social Security Number, the
percentage of ownership, the position/title held within the
regional center (if any), and any other names or aliases used.
All such principals are required to provide a copy of a valid
government-issued photo identification document and should provide
a U.S. Social Security Number. For any owner that is an entity or
organization, provide the entity's name, its percentage of
ownership, the Federal Employer Identification Number, any trade
name (DBA), and list the name of all persons having ownership,
control, or a beneficial interest in that entity or organization,
their date of birth, country of birth, the percentage of
ownership, and the position held (if any) within the entity or
organization. For each owner, provide the mailing address,
telephone number, email address, and website address. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
…
[Page 3]
5. U.S.
Social Security Number (if any)
…
7. Position Held Within the
Regional Center Entity (if any)
…
10.e.
Position Held (if any) in the Entity Listed in Part 4.,
Item Number 8.
Other Names Used By the Owners
of the Regional Center Entity (if
applicable)
…
12. Trade
Name (DBA if any) (for the entity listed in Part 4., Item
Number 8.)
Mailing Address for the Owners
of the Regional Center Entity
13.a. In
Care Of Name (if any)
13.b. Street Number and Name
or PO Box
13.c. Apt. Ste. Flr.
13.d. City or Town
13.e. State
13.f. ZIP
Code
13.g.
Province
13.h.
Postal Code
13.i.
Country
…
16. Email
Address (if any)
17. Website
Address (if any)
[Page 4]
…
List all principals associated with
the regional center, other than those already identified in Part
4., Item Numbers 2.a. - 12. For each person,
include the principal non-owner's name, date of birth, country of
birth, U.S. Social Security Number, the position/title held within
the regional center entity, and any other names or aliases used.
All principals are required to provide a copy of a valid
government-issued photo identification document and should provide
a U.S. Social Security Number. For each principal that is an
entity or organization, provide the name of the entity, the
Federal Employer Identification Number, any trade name (DBA), and
list the names of all persons having ownership, control, or a
beneficial interest in that entity or organization, their date of
birth, country of birth, the percentage of ownership, and the
position held (if any) within the entity or organization. For
each principal, provide the mailing address, telephone number,
email address, and website address. If you need extra space to
complete this section, use the space provided in
Part 10. Additional Information.
…
21. U.S. Social Security
Number (if any)
…
25.e.
Position Held (if any) in the Entity Listed in Part 4.,
Item Number 23.
Other Names Used By the
Principal Non-Owner of the Regional Center Entity (if
applicable)
…
27. Trade Name (DBA if any)
(for the entity listed in Part 4., Item Number 23.)
Mailing Address For the
Principal Non-Owners of the Regional Center Entity
28.a.
In Care Of Name (if any)
28.b. Street Number and Name
or PO Box
28.c. Apt. Ste. Flr.
28.d. City or Town
28.e. State
28.f. ZIP
Code
28.g.
Province
28.h.
Postal Code
28.i.
Country
[Page 5]
…
31. Email Address (if any)
32. Website Address (if any)
…
|
[Page 2]
…
List all
persons or legal entities or organizations that own or have a
percentage of ownership in the regional center entity. For
persons, include each owner's name, date of birth, country of
birth, U.S. Social Security Number, the percentage of ownership,
the position/title held within the regional center,
and any other names or aliases used. All such principals
are required to provide a copy of a valid government-issued photo
identification document and should provide a U.S. Social Security
Number. For any owner that is an entity or organization, provide
the entity's name, its percentage of ownership, the Federal
Employer Identification Number, any trade name (DBA), and list the
name of all persons having ownership, control, or a beneficial
interest in that entity or organization, their date of birth,
country of birth, the percentage of ownership, and the position
held within the entity or
organization. For each owner, provide the mailing address,
telephone number, email address, and website address. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
…
[Page 3]
5.
U.S. Social Security Number
…
7. Position Held Within the
Regional Center Entity
…
10.e.
Position Held in the Entity
Listed in Part 4., Item Number 8.
Other Names Used By the Owners
of the Regional Center Entity
…
12. Trade
Name (DBA) (for the entity listed in
Part 4., Item Number 8.)
Mailing Address for the Owners
of the Regional Center Entity
13.a. In
Care Of Name
13.b. Street Number and Name
or PO Box
13.c. Apt. Ste. Flr.
13.d. City or Town
13.e. State
13.f. ZIP
Code
13.g.
Province
13.h.
Postal Code
13.i.
Country
…
16. Email
Address
17. Website
Address
[Page 4]
…
List all principals associated with
the regional center, other than those already identified in Part
4., Item Numbers 2.a. - 12. For each person,
include the principal non-owner's name, date of birth, country of
birth, U.S. Social Security Number, the position/title held within
the regional center entity, and any other names or aliases used.
All principals are required to provide a copy of a valid
government-issued photo identification document and should provide
a U.S. Social Security Number. For each principal that is an
entity or organization, provide the name of the entity, the
Federal Employer Identification Number, any trade name (DBA), and
list the names of all persons having ownership, control, or a
beneficial interest in that entity or organization, their date of
birth, country of birth, the percentage of ownership, and the
position held within the entity or
organization. For each principal, provide the mailing address,
telephone number, email address, and website address. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
…
21. U.S. Social Security
Number
…
25.e.
Position Held in the Entity
Listed in Part 4., Item Number 23.
Other Names Used By the
Principal Non-Owner of the Regional Center Entity
…
27. Trade Name (DBA)
(for the entity listed in Part 4., Item Number
23.)
Mailing Address For the
Principal Non-Owners of the Regional Center Entity
28.a.
In Care Of Name
28.b. Street Number and Name
or PO Box
28.c. Apt. Ste. Flr.
28.d. City or Town
28.e. State
28.f. ZIP
Code
28.g.
Province
28.h.
Postal Code
28.i.
Country
[Page 5]
…
31. Email Address
32. Website Address
…
|