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Form LIC 9052 Employee rights. personnel record (form to be completed by employee) date name of facility facility address facility file number 1. personal name (last first middle) telephone ... lic 501 (3/99) 3. education (continued) name university, college or business school and address major subject no. (11) Personnel Record - LIC 501 (8/87) (12) Health Screening Report - Facility Personnel - LIC 503 (9/86) (13) Disaster and Mass Casualty Plan - LIC 610 (10/88) (b) The applicant/licensee shall cooperate with the Department in providing verification and/or documentation as requested by the Department. personnel record lic 501: personnel record lic 501. if yes, list all names used. Open Records Request Requests for records maintained by the Kentucky Personnel Cabinet may be submitted to the Office of Legal Services, Custodian of Records via one of the methods listed below. Form LIC 508 Criminal record statement. Form LIC 9188 Criminal record exemption transfer request. 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