Application Form & Full Disclosure Of Ownership Statement For An Amended License By An Individual, Partnership, Limited Liability Company Or Corporation

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Division of Public Health –Licensure Unit–Children's Services Licensing
Application & Full Disclosure of Ownership Statement for an Amended License
by an Individual, Partnership, Limited Liability Company or Corporation
READ CAREFULLY, USE BLACK INK, PRINT LEGIBLY AND FOLLOW ENCLOSED INSTRUCTIONS
LICENSE TYPE: (CHECK ONE)
FAMILY CHILD CARE HOME I
FAMILY CHILD CARE HOME II
CHILD CARE CENTER
SCHOOL-AGE-ONLY CENTER
PRESCHOOL
PROGRAM LICENSE NUMBER ____________________
THIS APPLICATION MUST BE SIGNED AND DATED
TYPE OF AMENDMENT
Check all that apply:
Change Licensed Days of Operation
Add:
Household Member
Staff
Substitute
Volunteer
Change Licensed Hours of Operation
Change License Capacity
List All Name(s) Added: __________________________________
Change Licensed Age Range
_______________________________________________________
Change/Add Space
_______________________________________________________
_______________________________________________________
Describe: ______________________________________________
_______________________________________________________
_______________________________________________________
Check all that apply:
Address Change – (provide new address below in Section A
Remove:
number 4)
Household Member
Staff
Substitute
Volunteer
Effective Move date: ___________________________________
List All Name(s) Removed: ________________________________
Preferred Mailing Address Change
_______________________________________________________
Add/Change Director
_______________________________________________________
Add/Change Primary Provider
_______________________________________________________
_______________________________________________________
Licensee's Name Change
Add Partner(s)
Program Name Change
Other: _______________________________________________
_______________________________________________________
_______________________________________________________
Complete all the following sections that are applicable to your facility. Refer to instructions for more detailed information.
SECTION A - IDENTIFYING INFORMATION:
1.
Name of Program: ________________________________________________________________________________________________
2.
Name of Applicant: _______________________________________________ 3. Social Security Number: ____________________________
Name of Applicant: _______________________________________________
Social Security Number: ____________________________
4.
Physical Address of Program: __________________________________________________________
___________________________
(Street, City, Zip Code)
(County)
5.
Program Phone Number/Cell Phone with Area Code: ______________ 6. Fax Number with Area Code (if applicable): __________________
7.
Email (optional): _________________________________________________________________________________________________
8.
Director/Primary Provider: _________________________________________________________________________________________
Name
9.
License Capacity: __________________ 10. Licensed Age Range: ________________ (wks, mos, yrs) to ________________ (mos, yrs)
11. Licensed Hours of Operation (specify whether A.M. or P.M. hours): ______________ to ______________
OR
24 Hour Care
12. Licensed Days of Operation: (check all that apply):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
13. Preferred Mailing Address For Receipt Of Official Correspondence From The Department, if different than #4:
__________________________________________________________________________________________________________________
(PO Box, Street, City, Zip Code)
Distribution: WHITE: Central Office; CANARY: Children's Services Licensing; PINK: Provider/Applicant
1
CRED-0949 (25023) 5/14

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