Any person desiring a license issued pursuant to Section 1639.3 shall file with the state department a verified application on forms prescribed by the state department containing all of the following:

1. (a) The name of the applicant for licensure.
2. (b) The street address of the tissue bank. If more than one street address is occupied by the tissue bank, all occupied street addresses shall be listed.
3. (c) Whether the applicant is an individual, partnership, unincorporated association, or corporation.
4. (d) Whether the applicant does business under a fictitious name, and, if so, the fictitious name and the name of the locality wherein any fictitious name permit is filed.
5. (e) If the applicant is a partnership, the names of all the members of the partnership, or unincorporated association, whether general or limited.
6. (f) If the applicant is a corporation, the name of the officers, directors, shareholders holding a 5 percent or more interest in the corporation, and any person, partnership, or corporation who or which has the responsibility to manage or conduct the day-to-day operation of the tissue bank.
7. (g) The type of tissue collected, processed, stored, or distributed by the tissue bank.
8. (h) The names, titles, and qualifications of the persons responsible for the collection, processing, storage, or distribution of tissue by the tissue bank.
9. (i) Any process utilized by the tissue bank to ensure safe preservation, transportation, storage, and handling, of tissue acquired or used by the tissue bank.
10. (j) Any process utilized by the tissue bank to determine if, when appropriate, donors have been tested to determine compatibility.
11. (k) Any process utilized by the tissue bank to determine if donors have been tested or assessed for the transmission of disease through transplantation.