Application Form & Full Disclosure Of Ownership Statement For An Amended License By An Individual, Partnership, Limited Liability Company Or Corporation Page 7
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9Division Public Health–Licensure Unit–Children's Services Licensing
Instructions to Complete Application to Amend License by an
Individual, Partnership, Limited Liability or Corporation
THESE INSTRUCTIONS ARE TO ASSIST YOU IN COMPLETEING 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. Name of Applicant: The Applicant is the owner of the program. May also be known as the “Licensee” – means the owner of
the child care program and the individual, partnership, limited liability company, or corporation to whom the license is issued
and who is responsible for compliance with all regulations.
If you are an individual or individual(s) enter your legal name(s) (Last, First, Middle Initial)
If you are in a partnership, enter all individual’s names.
If you are a Limited Liability Company, enter the Limited Liability Company name.
If you are a Corporation, enter the name of the Corporation.
3. Social Security Numbers: Individual owners, partners and members of the Limited Liability Companies are required to
provide their Social Security Numbers. Social Security Numbers will not be released without the individual’s consent except as
required by law.
4. 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 I’s must be in your residence. Family Child Care Home II’s, Child
Care Centers, Preschools, and School-Age-Only Centers can be in your residence or another approved location.
5. Program Phone Number/Cell Phone with Area Code: Enter the Phone Number of the program and/or cell phone with area
code. 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, note change on application.
6. FAX Number with Area Code (if applicable): Enter the Fax number with area code. This is optional. If this is a new Fax
number, note change on application.
7. E-mail (optional): Enter your email address.
8. 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.
9. 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.
10. 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.
11. 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.
12. 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.
13. 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, check the box titled "other", and note the change.
CRED-0949 (25023) 5/14
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