Application For Licensed Type B Home - Licking County Job And Family
ADVERTISEMENT
1
2
3
4Ohio Department of Job and Family Services
APPLICATION FOR LICENSED TYPE B HOME
Section I - To Be Completed by County Department of Job and Family Services (CDJFS)
Home Telephone Number
Mobile Telephone Number
Submit this Application to (CDJFS name and address):
Name of CDJFS staff
Status of Application:
Date Application Submitted
Date Provider Agreement
Date BCII/FBI Checks Submitted
Completed
Date BCII Results Received
Date FBI Results Received
Date PCSA Request Submitted
Date PCSA Results Received
Date Initial Inspection Completed
Date Certificate Issued
Date Application Denied
Date License Recommended
Date License Issued
The information in Section II through Section V will give us an idea of the types of services you may be able to provide.
However, your answers to these questions will not be taken as a final commitment. The CDJFS staff will discuss this
information with you.
Section II - General Information
Name of Applicant
Birth Date
Social Security Number
E-Mail Address (required)
Address
Previous Last Names of Applicant
Telephone Number
City, State, and Zip Code
What is your educational level?
High School Graduate
Date
Which children are you willing to care for?
GED Diploma
Date
Infants (0-18 months)
Degree
College Graduate
Date
Toddlers (18-36 months)
Preschool children
How many of your own children are under the age of six?
Name:
Age:
School children
Children with special needs
When do you prefer to care for children?
Weekdays
Weekends
How many children other than your own are you caring for at this time?
Overnight
List their names and ages:
Are you presently employed inside or outside your own home?
Yes
No
If yes, complete the
chart below.
Name of Employer
City
Address
State
Zip Code
JFS 01643 (Rev. 1/2014)
Page 1 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Jfs 01332 - Child Care Handbook For Caretakers Licensed Type B Home Providers And Certified In-home Aides
Legal
Application For Voluntary Successorship: Transfer Of Clearly Segregable And Identifiable Portion Form - Ohio Department Of Job And Family Services
Legal
Application For Search Of Ohio Putative Father Registry - Ohio Department Of Job And Family Services
Business
Related Categories
Parent category: Business