Application Form & Full Disclosure Of Ownership Statement For An Amended License By A Non-Profit Corporation Or Governmental Unit Page 5
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6Division of Public Health–Licensure Unit–Children's Services Licensing
Instructions to Complete Application & Full Disclosure of Ownership Statement for
an Amended License by a Non-Profit Corporation or Governmental Unit
THESE INSTRuCTIONS ARE TO ASSIST YOu IN COMPLETING THE APPLICATION. DO NOT RETuRN WITH APPLICATION.
NOTE: ADDITIONAL DOCuMENTS MAY bE REQuIRED FOR THE TYPE OF AMENDMENT FOR WHICH YOu ARE REQuESTING.
SECTION A - IDENTIFYING INFORMATION:
1. Name of Program:
If amending the Name of the Program, enter the new name of the facility. If not, refer back to the name currently printed on
your child care/preschool license.
2. Physical Address of Program:
Enter the new physical address, if amending location. If not amending, enter physical address where program is located.
Family Child Care Home II’s, Child Care Centers, Preschools, and School-Age-Only Centers can be in your residence or
another approved location.
3. Program Phone Number/Cell Phone with Area Code:
Enter the Phone Number and /or cell phone with area code for the program. You are required to have an operating phone on
the premises of the program. A cell phone is acceptable. If this is a new phone number make a note on the application.
4. FAX Number with Area Code (if applicable):
Enter the Fax number with area code. This is optional. If this is a new Fax number make a note on the application.
5. E-mail (optional):
Enter your email address.
6. Director/Primary Provider:
Enter the name of the new Director/Primary Provider. If not amending, enter the name of the current Director/Primary Provider
who is responsible for the daily operation of the child care/preschool program including compliance with all regulations.
7. License Capacity:
If amending the capacity enter the new capacity number. If not amending, refer back to the capacity currently printed on
your child care/preschool license. The number of children in care at any one time must not exceed the licensed capacity.
8. Licensed Age Range:
If amending ages enter the new age range you are requesting. If not amending, refer back to the age range currently printed
on your child care/preschool license.
9. Licensed Hours of Operation:
If amending hours enter the new hours you are requesting. If not amending, refer back to the hours of operation currently
printed on your child care/preschool license. You may not provide care for children outside of your licensed hours. Any hours
between 9 P.M. and 6 A.M. are considered overnight care. Refer to the regulations regarding overnight care.
10. Licensed Days of Operation:
If amending days enter the new days you are requesting. If not amending, refer back to the days of operation currently printed
on your child care/preschool license.
11. Preferred Mailing Address for Receipt of Official Correspondence from the Department:
Enter the address where all mail from the Department/Children’s Services Licensing should be sent. Include Street Address,
PO Box # (if applicable), City, State, and Zip Code. If this amendment is a new mailing address, mark the box titled “other”
and note this change.
12. Person(s) designated by the Owner of the Program to Sign Amendment Applications and other Licensing
Documents. List Names and Title(s) (i.e., Authorized Agent/Representative, Director/Primary Provider, or
Administrator):
If the owner of the program would like to designate a new person to sign applications and other licensing documents, list
them here; i.e., Director, etc. If not the owner may enter the name of the current individual from the previous application.
CRED-0956 (25023) 6/14
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