How to Fill Out California CDI Notice of Appointment (w/Examples) + FAQs

The California CDI Notice of Appointment is the form an insurance company files with the California Department of Insurance (CDI) to officially attach a licensed producer or business entity to that company so the producer can sell, solicit, or negotiate the company’s policies in California. Insurers must file the appointment within 14 days of the date the producer first submits an application, binds coverage, or accepts compensation under California Insurance Code §1704, and a missed appointment can void commissions and trigger fines.

CDI processes more than 300,000 producer appointments and renewals each year through the Sircon for California and NIPR Appointment Service portals, and the CDI Producer Licensing Bureau reports that roughly 1 in 7 paper LIC NA forms is rejected for missing data, wrong NAIC codes, or unsigned officer blocks. This article shows you exactly how to complete both the individual (LIC NA) and business-entity (LIC NAB) versions of the form, line by line, with named examples.

Here is what you will learn:

  • 📝 How to fill in every box on the LIC NA and LIC NAB without triggering a CDI rejection
  • 💵 The current $29 per-appointment fee, the 14-day filing window, and the late penalties under CIC §1704.5
  • 🧾 Three full walkthrough scenarios for individual, business-entity, and non-resident appointments
  • ⚠️ The 10 most common mistakes that delay or void an appointment
  • 15 FAQs covering field-level confusion, NAIC codes, lines of authority, and termination

What the CDI Notice of Appointment Is and Who Must File It

The CDI Notice of Appointment is the legal instrument that creates an agency relationship between a licensed insurer and a licensed producer in California. The current paper version is LIC NA (Rev. 06/2024) for individuals and LIC NAB (Rev. 06/2024) for business entities, both posted on the CDI Producer Licensing Forms page. The form is required by California Insurance Code §1704, which states that no person shall act as an agent for any insurer until that insurer has filed a notice of appointment with the commissioner.

Only admitted insurers licensed by CDI can file an appointment, and only producers who already hold an active California license with the matching line of authority can be appointed. A property broker-agent, for example, cannot be appointed for life lines until they pass the life exam and add that authority to their license. A surplus lines broker is appointed differently and uses a separate filing through the Surplus Line Association of California, so do not confuse the two.

The filer is almost always the appointing insurer’s licensing department or its designated compliance vendor, although managing general agents (MGAs) with a power of attorney from the insurer may file on the insurer’s behalf. The producer being appointed never files the LIC NA themselves. A common misconception is that an “appointment” and a “license” are the same; they are not. The license lets you sell insurance in California, but the appointment is what lets you sell that specific company’s products.

Before You Start: Documents and Information You Need

Gather every piece of data before you open the form, because Sircon and NIPR will time out a session and CDI will reject a paper LIC NA that has even one blank required field. Missing items are the single biggest cause of rejection, according to the CDI Licensing Bureau status reports.

  • Insurer NAIC company code (5 digits). Without the correct NAIC code from the NAIC Company Search, CDI cannot match the appointment to your admitted insurer record and will return the form.
  • Insurer CDI company number. This is the California-issued company ID, distinct from the NAIC number, and CDI uses it for billing the $29 fee.
  • Producer’s California license number (8 digits). Pull it from the CDI License Status Inquiry so you do not transpose digits.
  • Producer’s full legal name. It must match the name on file with CDI exactly, including middle initial and suffix.
  • Producer’s National Producer Number (NPN). Found on the NIPR PDB lookup, the NPN is required for all electronic appointments.
  • Lines of authority to be appointed. You must know whether you are appointing for Life-Only, Accident & Health, Property, Casualty, Personal Lines, Variable Contracts, or another LOA, because each line is a separate appointment fee.
  • Effective date of the appointment. Per CIC §1704(a), this is the earliest of the date the producer’s first application was signed, coverage was bound, or compensation was accepted.
  • Appointing officer’s name, title, and signature authority. The officer signing the LIC NA must be a corporate officer of the insurer or hold a recorded power of attorney.
  • Payment method. Sircon and NIPR accept ACH and credit card; paper filings require a check or money order made payable to the California Department of Insurance.
  • Business entity license number (for LIC NAB only). Agencies have their own 8-digit California license number that is separate from any owner’s individual license.

Where to Get the Form and How to Access It

The official LIC NA and LIC NAB are posted as fillable PDFs on the CDI Forms and Fees page. Always download a fresh copy each filing cycle because CDI updates the revision date in the bottom-left footer when fields change, and the agency rejects forms that are more than one revision out of date.

Most California insurers do not use the paper form at all. Instead, they file electronically through Sircon for California, operated by Vertafore, or through the NIPR Appointment Service operated by the National Insurance Producer Registry. Both portals push the appointment data directly into CDI’s licensing system the same business day, while paper filings can take 6 to 8 weeks to post, according to current CDI processing-time bulletins.

To use Sircon or NIPR, the insurer must have a registered company account, an authorized user with login credentials, and a funded payment account. New insurers should request the CDI Producer Licensing Bureau onboarding packet at least 30 days before they expect to make their first appointment so the company NAIC and CDI numbers are loaded into both portals. Filing without that setup is the most common reason a brand-new insurer’s first round of appointments fails.

Step-by-Step: How to Fill Out the LIC NA and LIC NAB Line by Line

The following walkthrough covers every field on the paper LIC NA (individual) and LIC NAB (business entity), in the order printed on the form. The same data points appear on the Sircon and NIPR electronic screens, just with different layouts. Use the CDI LIC NA fillable PDF as your reference while you read.

Box 1 – Insurer NAIC Company Code

This box asks for the 5-digit NAIC code that uniquely identifies the appointing insurer.

To answer it, look up your company on the NAIC Company Search tool and copy the 5-digit number into the box, right-justified, with leading zeros if needed.

For example, Pacific Mutual Insurance Company enters 69876 in Box 1.

A common edge case is a holding company that owns several admitted insurers; each carrier has its own NAIC code, and a single LIC NA can only appoint a producer to one carrier at a time.

The most common mistake is using the parent group code instead of the individual entity code, and the consequence is that CDI cannot match the appointment to a licensed admitted insurer, so the form is returned and the 14-day clock keeps running.

A misconception filers carry is that the NAIC code and the CDI company number are interchangeable; they are not, and Box 1 specifically asks for the NAIC code.

Box 2 – CDI Company Number

This field asks for the California-issued company identification number assigned by CDI when the insurer became admitted.

Enter the number exactly as it appears on the insurer’s CDI Certificate of Authority, with no dashes or spaces.

For example, Pacific Mutual Insurance Company writes 2841-7 in Box 2.

If your company recently re-domesticated or changed names, the CDI number stays the same; only the company name field changes.

A common mistake is leaving Box 2 blank because the filer assumes the NAIC code in Box 1 is enough, and the consequence is automatic rejection at CDI’s intake.

The misconception is that CDI can “look up” the company from the name alone; it cannot, because several admitted insurers share similar names.

Box 3 – Insurer Legal Name

This field asks for the full legal name of the appointing insurer as recorded on its Certificate of Authority.

Type the name in ALL CAPS exactly as it appears on the certificate, including punctuation like commas and the words Insurance Company spelled out.

For example, Pacific Mutual Insurance Company enters PACIFIC MUTUAL INSURANCE COMPANY in Box 3.

If the insurer uses a DBA in California, the DBA goes in a separate “Also Known As” line, not Box 3.

The most common mistake is using a marketing name or a parent-company name, and the consequence is that CDI cannot reconcile the filing with its admitted carrier list.

A misconception is that abbreviations like Ins. Co. are acceptable; CDI requires the legal name exactly as filed.

Box 4 – Producer’s California License Number

This field asks for the producer’s 8-digit California license number.

Pull the number from the CDI License Status Inquiry, enter all 8 digits with no dashes, and double-check it against the producer’s pocket license.

For example, when appointing Maria Lopez, the filer enters 0H123456 in Box 4.

If a producer’s license is in a “pending renewal” status, the appointment can still be filed, but if the license has lapsed, CDI will reject the LIC NA until the producer reinstates.

A common mistake is using the producer’s NPN in this box instead of the California license number, and the consequence is an automatic mismatch error in Sircon/NIPR.

The misconception is that the license number ever changes; it does not, even when the producer renews or moves.

Box 5 – Producer’s Full Legal Name

This field asks for the producer’s full legal name.

Enter the name in Last, First Middle order in ALL CAPS, matching exactly what is on file with CDI.

For example, the filer enters LOPEZ, MARIA ELENA in Box 5.

If the producer recently changed names through marriage or court order, they must update CDI through the Name Change request before the appointment is filed; otherwise the names will not match.

The most common mistake is entering a nickname or shortened first name like Mary instead of Maria, and the consequence is a “name mismatch” rejection.

A misconception is that middle names are optional; if the middle name is on the license, it must be on the LIC NA.

Box 6 – National Producer Number (NPN)

This field asks for the producer’s NIPR-assigned NPN.

Look up the NPN through the NIPR PDB Lookup and enter it as a numeric string.

For example, Maria Lopez has NPN 17654321, which goes in Box 6.

The NPN follows the producer across states, so a non-resident appointment uses the same NPN as the producer’s home-state license.

The most common mistake is leaving Box 6 blank for a resident California producer, and the consequence is that the electronic feed to NIPR’s PDB cannot post the appointment record.

A misconception is that the NPN is optional for paper filings; CDI now requires it on every LIC NA revised after 2019.

Box 7 – Producer’s Residence Address

This field asks for the producer’s current California residence address on file with CDI.

Enter street, city, state, and 5-digit ZIP code; do not use a P.O. Box because CIC §1704 requires a physical residence.

For example, Maria Lopez enters 1422 Olive Street, Long Beach, CA 90802.

If the producer recently moved, they must file a CDI Address Change within 30 days before the appointment is filed.

The most common mistake is using the agency’s business address in Box 7 instead of the producer’s residence, and the consequence is a CDI rejection for inconsistent records.

A misconception is that residence and mailing address are the same; on this form, residence means physical home address.

Box 8 – Lines of Authority Being Appointed

This field asks which lines of authority the insurer is appointing the producer to write.

Check every box that applies: Life-Only, Accident & Health, Property, Casualty, Personal Lines, Variable Contracts, Limited Lines Automobile, or other limited lines.

For example, Pacific Mutual checks Life-Only and Accident & Health for Maria Lopez.

A producer can only be appointed for lines they already hold on their California license; if a producer holds Property only and you check Casualty, the appointment will reject.

The most common mistake is checking all lines as a precaution, and the consequence is that the insurer pays a $29 fee for every checked line and may be billed for lines the producer cannot legally write.

A misconception is that “Personal Lines” is a subset of Property and Casualty; under CIC §1625.5, it is a separate, narrower line of authority.

Box 9 – Effective Date of Appointment

This field asks for the date the appointment is effective.

Enter the date in MM/DD/YYYY format; under CIC §1704(a), it is the earliest of the date the producer first submits an application, binds coverage, or accepts compensation for the insurer.

For example, Maria Lopez signed her first application for Pacific Mutual on March 14, 2026, so the filer enters 03/14/2026.

If the appointment is back-dated more than 14 days, CDI will assess a late filing fine under CIC §1704.5.

The most common mistake is entering the date the LIC NA was prepared rather than the date the producer first acted, and the consequence is an under-reported lookback that comes up in CDI market conduct exams.

A misconception is that a future-dated appointment is allowed; CDI will reject any effective date later than the date of filing.

Box 10 – Appointing Officer’s Name and Title

This field asks for the printed name and corporate title of the insurer officer who has authority to appoint producers.

Enter the officer’s full name and title, such as Vice President of Distribution, Chief Marketing Officer, or Corporate Secretary.

For example, Pacific Mutual prints JAMES R. CHEN, VICE PRESIDENT OF AGENCY in Box 10.

If the person signing is not a listed officer, the insurer must attach a board-approved power of attorney to the LIC NA.

The most common mistake is having a producer-licensing manager sign without officer authority, and the consequence is a CDI rejection that voids the entire batch.

A misconception is that any executive can sign; only an officer of record or POA holder can.

Box 11 – Officer Signature and Date

This field asks for the wet or electronic signature of the appointing officer and the date signed.

Sign in blue or black ink for paper filings, or apply an authenticated e-signature in Sircon/NIPR; date in MM/DD/YYYY.

For example, James R. Chen signs and dates 03/16/2026.

The signature date can differ from the effective date in Box 9, but it must not be earlier than the effective date.

The most common mistake is leaving the signature undated, and the consequence is that CDI cannot validate the 14-day filing window.

A misconception is that a stamped signature is acceptable; CDI requires a wet or authenticated electronic signature.

Box 12 (LIC NAB Only) – Business Entity License Number and FEIN

On the LIC NAB, this field asks for the agency’s 8-digit California license number and 9-digit Federal Employer Identification Number.

Enter the agency license from the CDI License Status Inquiry and the FEIN exactly as it appears on the entity’s IRS letter.

For example, Sunrise Insurance Services, LLC enters license 0K987654 and FEIN 87-1234567.

If the entity is a sole proprietorship using the owner’s SSN instead of an FEIN, the LIC NAB cannot be used; the insurer must use the LIC NA on the individual instead.

The most common mistake is entering an owner’s SSN, and the consequence is a privacy violation plus an instant CDI rejection.

A misconception is that one LIC NAB covers all sub-producers of the agency; it does not, and each sub-producer needs a separate LIC NA.

Three Filled-Out Examples Using Real Scenarios

The following three scenarios show how three different filers complete the form from start to finish. Each scenario uses real-world fact patterns drawn from the most common CDI appointment types.

Scenario 1 – Maria Lopez, newly licensed individual P&C agent appointed by Pacific Mutual.

Form Section What Pacific Mutual’s Filer Enters for Maria
Box 1 NAIC code 69876
Box 2 CDI company number 2841-7
Box 3 Insurer legal name PACIFIC MUTUAL INSURANCE COMPANY
Box 4 Producer license number 0H123456
Box 5 Producer name LOPEZ, MARIA ELENA
Box 6 NPN 17654321
Box 7 Residence 1422 Olive Street, Long Beach, CA 90802
Box 8 Lines of authority Property, Casualty, Personal Lines
Box 9 Effective date 03/14/2026
Box 10 Officer JAMES R. CHEN, VP OF AGENCY
Box 11 Signature/date J. Chen 03/16/2026
Filing channel Sircon for California, $87 (3 lines × $29)

Scenario 2 – Sunrise Insurance Services LLC, a business entity appointed for life and health by Golden State Life.

Form Section What Golden State Life’s Filer Enters for Sunrise
Box 1 NAIC code 71234
Box 2 CDI company number 3552-1
Box 3 Insurer legal name GOLDEN STATE LIFE INSURANCE COMPANY
Box 4 Entity license number 0K987654
Box 5 Entity legal name SUNRISE INSURANCE SERVICES, LLC
Box 6 Entity NPN 19876543
Box 7 Principal business address 5500 Wilshire Blvd, Suite 400, Los Angeles, CA 90036
Box 8 Lines of authority Life-Only, Accident & Health, Variable Contracts
Box 9 Effective date 04/01/2026
Box 10 Officer PATRICIA OWENS, CHIEF DISTRIBUTION OFFICER
Box 11 Signature/date P. Owens 04/02/2026
Box 12 FEIN 87-1234567

Scenario 3 – Aiden Park, a non-resident life agent licensed in Texas, appointed by Bay Bridge Life through NIPR.

Form Section What Bay Bridge Life’s Filer Enters for Aiden
Box 1 NAIC code 60123
Box 2 CDI company number 4101-9
Box 3 Insurer legal name BAY BRIDGE LIFE INSURANCE COMPANY
Box 4 Non-resident license number 4001234
Box 5 Producer name PARK, AIDEN J.
Box 6 NPN 20112233
Box 7 Residence 812 Magnolia Lane, Austin, TX 78704
Box 8 Lines of authority Life-Only, Variable Contracts
Box 9 Effective date 05/05/2026
Box 10 Officer DAVID NGUYEN, CORPORATE SECRETARY
Filing channel NIPR Appointment Service, $58 (2 lines × $29)

Other named filers you’ll see referenced throughout this guide include Janet Reyes, a compliance manager at a large auto insurer who files 2,000 appointments a quarter through Sircon, and Marcus Hill, a small-MGA owner who files paper LIC NAs by mail.

How to File the Completed Form

CDI accepts appointments through three channels, and the channel you choose affects fees, processing times, and proof-of-filing.

Sircon for California (electronic, recommended). File at Sircon’s California portal; the fee is $29 per line of authority, paid by ACH or credit card; processing is same-business-day; your proof of filing is the Sircon transaction confirmation number, which you should save as a PDF in the producer’s file.

NIPR Appointment Service (electronic). File at the NIPR Appointment Service; the fee is $29 per line of authority plus a small NIPR transaction fee; processing is same-business-day; your proof of filing is the NIPR confirmation email and PDB record update.

Paper LIC NA / LIC NAB by mail. Mail the signed original to California Department of Insurance, Producer Licensing Bureau, 320 Capitol Mall, Sacramento, CA 95814; include a check or money order payable to the California Department of Insurance for $29 per line; processing takes 6 to 8 weeks; your proof of filing is your certified-mail receipt and the cashed check.

There is no in-person counter filing for appointments; CDI closed walk-in licensing services in 2018. Fax filings are not accepted for new appointments. Janet Reyes, the compliance manager mentioned earlier, files exclusively through Sircon and keeps her transaction confirmations in a SharePoint folder organized by NAIC code, which is the practice the CDI Licensing Bureau recommends in its producer-licensing FAQs.

What Happens After You File

Once Sircon or NIPR transmits the appointment, CDI’s licensing system validates the producer’s license status, the lines of authority, and the appointing insurer’s admitted status. If everything matches, the appointment posts to the producer’s public license record within 24 hours, and the producer can begin transacting that insurer’s business immediately.

If something does not match, CDI sends a rejection notice through the same channel that filed it. The most common rejection reasons are name mismatch, license expired, and missing NPN. The insurer has 30 days to cure the rejection without losing the original effective date; after 30 days, CDI requires a new filing with a new effective date.

Appointments renew automatically each year as part of the insurer’s annual appointment renewal under CIC §1708. The renewal sweep happens between November and January, and insurers receive a Sircon-generated invoice listing every active appointment with the $29 renewal fee per line. Failing to pay the renewal invoice automatically terminates every appointment on the list and forces the insurer to re-file each one as a new appointment.

Mistakes to Avoid When Filling Out the Form

  • Using the parent-group NAIC code instead of the entity NAIC code. The appointment will not match the admitted carrier and CDI will return it.
  • Leaving the NPN blank on a resident appointment. NIPR cannot post the record without the NPN, voiding the filing.
  • Checking lines of authority the producer does not hold. CDI rejects the entire form, not just the bad line.
  • Entering a P.O. Box in the residence field. Per CIC §1704, the residence must be a physical address.
  • Filing more than 14 days after the trigger date. Late fees of up to $200 per appointment apply under CIC §1704.5.
  • Future-dating the effective date. CDI bounces any appointment with a Box 9 date after the filing date.
  • Letting a non-officer sign Box 11. The appointment is void without officer or POA-holder authority.
  • Confusing the LIC NA with the LIC NT. The LIC NT terminates an appointment; using it to appoint produces no legal effect.
  • Paying with a personal check from the agent. CDI requires payment from the insurer or its authorized vendor.
  • Forgetting to keep the Sircon or NIPR confirmation. Without proof of filing, the insurer cannot defend a market-conduct exam finding.
  • Using a marketing name in Box 3. The legal Certificate of Authority name is required.
  • Skipping the FEIN on a LIC NAB. Without it, CDI cannot validate the entity’s IRS record.

Do’s and Don’ts

Do’s

  • Do download a fresh LIC NA or LIC NAB from CDI Forms before each filing, because revision dates change.
  • Do verify the producer’s license status the day you file, since lapses are the top rejection reason.
  • Do file electronically through Sircon or NIPR, because paper filings take 6–8 weeks.
  • Do save the confirmation as a PDF, because proof-of-filing is your only defense in a CDI exam.
  • Do calendar the 14-day filing window, since the late fee runs from the trigger date, not the discovery date.
  • Do reconcile every appointment against your monthly Sircon roster, because dropped appointments cost commissions.

Don’ts

  • Don’t appoint a producer “just in case”; the $29 fee per line adds up across 50-state operations.
  • Don’t let a non-officer sign Box 11, because the form is void without officer authority.
  • Don’t use the LIC NA to terminate; use the LIC NT Notice of Termination instead.
  • Don’t write commissions before the appointment posts; pre-appointment payments violate CIC §1704(a).
  • Don’t reuse old NAIC codes after a corporate restructure, because every entity has its own code.
  • Don’t ignore CDI rejection notices, because the 30-day cure window closes fast.

Pros and Cons of Filing on Your Own vs. With a Vendor

Pros of filing in-house

  • You control the data and the timing without waiting on a vendor queue.
  • You avoid third-party transaction fees on top of the $29 CDI fee.
  • You keep producer data inside your compliance perimeter for privacy reasons.
  • You build internal expertise that supports market-conduct exam responses.
  • You can customize internal workflows around your producer-onboarding system.

Cons of filing in-house

  • You must train staff on Sircon and NIPR, which takes weeks.
  • You assume liability for late filings and rejection cures.
  • You pay for software seats and user licenses for both portals.
  • You bear the cost of audit trails and document retention systems.
  • You handle every CDI inquiry, including weekend rejections.

Pros of using a licensing vendor

  • Vendors like Vertafore Sircon Managed Services file thousands of appointments daily and know every CDI rejection pattern.
  • Vendors absorb the burden of NIPR/Sircon maintenance and outages.
  • Vendors typically guarantee a same-day filing service-level agreement.
  • Vendors track effective dates and renewal sweeps automatically.
  • Vendors provide standardized reports for market-conduct exams.

Cons of using a licensing vendor

  • Vendor fees can run $5 to $15 per appointment on top of CDI’s $29.
  • You lose direct visibility into rejection root causes.
  • Vendor SLAs may not cover same-day filings for last-minute appointments.
  • Producer data leaves your direct control.
  • Switching vendors mid-cycle disrupts the renewal sweep.

LIC NA vs. LIC NAB at a Glance

Feature LIC NA (Individual) vs. LIC NAB (Business Entity)
Who is appointed LIC NA appoints a natural person; LIC NAB appoints a corporation, LLC, or partnership.
License number format LIC NA uses the 8-digit individual license; LIC NAB uses the 8-digit entity license.
FEIN required LIC NA does not require FEIN; LIC NAB requires it in Box 12.
Residence vs. business address LIC NA captures residence; LIC NAB captures principal business address.
Variable lines Both forms support Variable Contracts when the producer holds the LOA.
Sub-producer coverage Neither form covers sub-producers; each individual still needs a separate LIC NA.

FAQs

Do I need to file an appointment before the producer sells my products?

Yes. Under CIC §1704, the appointment must be filed within 14 days of the producer’s first application, binding, or compensation event for the insurer.

Is the appointment fee really $29 per line?

Yes. CDI charges $29 for every line of authority on every appointment, and the same fee applies again at each annual renewal under CIC §1708.

Can I appoint a producer whose license is in pending-renewal status?

Yes. A pending-renewal license is still active for appointment purposes, but if the license lapses before the cure period, the appointment will reject.

Do I write the producer’s NPN or California license number in Box 4?

No. Box 4 takes the 8-digit California license number; the NPN goes in Box 6, and mixing the two is the top rejection reason.

Can I use a P.O. Box in the residence field?

No. California requires a physical residence address in Box 7 because CIC §1704 ties producer accountability to a physical location.

Do I check every line of authority on the producer’s license?

No. Only check the lines you are actually appointing them to write, because each checked line costs $29 and may exceed the producer’s actual LOAs.

Is the effective date the date I sign the form?

No. Box 9 is the earliest of the date the producer first applied, bound, or accepted compensation for the insurer, not the prep or signing date.

Can a producer-licensing manager sign Box 11?

No. Only a corporate officer of the insurer or a documented power-of-attorney holder may sign the LIC NA or LIC NAB.

Is the LIC NA the same as the LIC NT?

No. The LIC NA appoints a producer, and the LIC NT terminates an appointment; using the wrong form has no legal effect.

Do I need a separate appointment for each line of authority?

Yes. Each line is a separate appointment with its own $29 fee, even though they may be filed in the same Sircon transaction.

Can I file the LIC NA by fax?

No. CDI does not accept fax filings; only Sircon, NIPR, or mail are accepted under current Producer Licensing Bureau rules.

Do I need to file a new appointment when a producer renews their license?

No. Producer license renewals do not affect existing appointments; insurer renewal sweeps under CIC §1708 keep the appointment active.

Is the FEIN required on a LIC NAB if the agency is a single-member LLC?

Yes. A single-member LLC must obtain and use an FEIN on the LIC NAB, because CDI does not accept SSNs in entity filings.

Can I appoint a non-resident producer with the same LIC NA?

Yes. Non-residents use the same LIC NA, but Box 4 takes their California non-resident license number and Box 7 takes their out-of-state residence.

Is back-dating an appointment allowed?

Yes. You can back-date the effective date in Box 9 to the true trigger event, but if it is more than 14 days back, CIC §1704.5 late fees apply.