Notification of Changes for Business Entity
General Information
Business Entity Name:	HOMELAND@WORK INC.
Incorporation / Formation Date:
FEIN:	462706522
Ohio License Number:	994622
NPN:
DBA / Trade Name:
State of Domicile:	GA
County:	FULTON
Business Address
Address 1:	4080 MCGINNIS FERRY RD. SUITE 1001
Address 2:
City:	ALPHARETTA
State:	GA
Zip:	30005
Phone:	2148712118
Fax:
Business Web Site Address:
Business Email Address:	LICENSING@HOMELANDHEALTHCARE.COM
Mailing Address
Address 1:	4080 MCGINNIS FERRY RD. SUITE 1001
Address 2:
City:	ALPHARETTA
State:	GA
Zip:	30005
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
GILBERT SANCHEZ	LICENSED PRODUCER	15702706	YES		01/20/2016
JASON JENNINGS	LICENSED PRODUCER	7557751	YES		01/20/2016
ABE ABTAHI	LICENSED PRODUCER	16608738	YES		01/20/2016
ERIC BANYON	LICENSED PRODUCER	8881189	YES		01/20/2016
KALEESHA STRANGE	LICENSED PRODUCER	13101019	YES		01/20/2016
PRISCILLA DAVIS	LICENSED PRODUCER	8901532	YES		01/20/2016
BRENDA BEE	LICENSED PRODUCER	17080063	YES		01/20/2016
MATTHEW MALONEY	LICENSED PRODUCER	17038108	YES		01/20/2016
MOISES SANTOS	LICENSED PRODUCER	17357743	YES		01/20/2016
PINKIE HICKS	LICENSED PRODUCER	8285198	YES		01/20/2016
EDWIN VELEZ	LICENSED PRODUCER	3490853	YES		01/20/2016
TRACI BROKER	LICENSED PRODUCER	17649369	YES		01/20/2016
STEPHANIE CENTER	LICENSED PRODUCER	1685508	YES		01/20/2016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	ROBERT J BYRNES
Title:	OWNER
Phone Number:	2148712118
Email Address:	LICENSING@HOMELANDHEALTHCARE.COM