NAME OF BUSINESS DISASSOCIATING FROM
BUSINESS MAILING ADDRESS (number/street or P.O. box)
NAME OF PERSON DISASSOCIATING
DAYTIME PHONE NUMBER
MAILING ADDRESS OF PERSON DISASSOCIATING (number/street or P.O. box)
DATE OF DISASSOCIATION
IF YOU ARE IN THE PROCESS OF OBTAINING A NEW LICENSE AND DO NOT WANT THIS
DOCUMENT PROCESSED UNTIL YOUR NEW LICENSE IS ISSUED, PLEASE CHECK HERE.
Use this form to notify CSLB of the disassociation of a Partner, Qualifying Partner, Officer, Responsible Managing Officer (RMO), or
Responsible Managing Employee (RME). This notice must be received at CSLB Headquarters within 90 days after the effective date
of the disassociation; if the notice is received after 90 days, the date CSLB receives it will be used as the disassociation date. This
may result in the suspension or cancellation of the license, or the removal of a classification from a license, effective that date. (See
Business & Professions Code Sections 7076, 7068.2, and 7083.)
DISASSOCIATION OF A PARTNER OR QUALIFYING PARTNER
If a partner disassociates from a license, it results in the cancellation of the partnership license. However, the remaining
partner(s) may request a continuance to complete projects in progress. A request for continuance must be received within
90 days of the cancellation date of the license.
DISASSOCIATION OF AN RME OR RMO
When an RME or RMO disassociates from a license, the licensee or qualifier must notify the Registrar in writing, and the licensee
must replace the qualifier within 90 days of the disassociation date. Failure to replace the qualifier within 90 days results in the
automatic suspension of the license or removal of the classification. If a licensee is unable to replace the RME or RMO within the
90-day period, a 90-day extension can be requested. An extension request must be received within 90 days after receiving
notification from CSLB that the license will be suspended or the classification removed.