License Cancellation Request Form
BUSINESS NAME (Exactly as it appears on CSLB records)
LICENSE NUMBER TO BE CANCELED
EFFECTIVE DATE OF CANCELLATION
BUSINESS MAILING ADDRESS NUMBER/STREET OR P.O. BOX
BUSINESS PHONE NUMBER
This form must be received at CSLB Headquarters within 90 days after the surrender,
disassociation or dissolution of a license. Failure to notify CSLB within 90 days will cause the
license to be canceled effective the date CSLB receives this form. (A request for a continuance
must be made in writing and received at the CSLB headquarters offi ce within 90 days of the
disassociation or dissolution—see Business & Professions Code Section 7076.)
• To cancel an individual license, this form must be signed by the owner.
• To cancel a partnership license, this form must be signed by a partner (but not a limited partner).
To cancel a corporate license, provide either of the following:
- The signatures of two offi cers shown on CSLB records: or
- A copy of the company’s fi nal dissolution documents fi led with the California Secretary of State.
• To cancel a joint venture license, this form must be signed by one of the individuals currently
listed on the license records of one of the entities.
I certify under penalty of perjury under the laws of the State of California that the information above is true and accurate.
On ___________________________ at ______________________________________________________________
Signature of Owner, Partner, or Offi cer _________________________________________________________________
Print Name _______________________________________________________________________________________
Signature of Owner, Partner, or Offi cer ________________________________________________________________