Application For Licensed Type B Home - Licking County Job And Family Page 3
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4Section IV - List the people living in your home, including children, foster children, relatives and
boarders
First and Last Name
Social Security Number
Birth Date
Relationship to Applicant
Please show that you have or are willing to provide the following:
Evidence of physical examination as required by certification rule 5101:2-14-02
Yes
No
A working telephone
Yes
No
A complete first aid kit
Yes
No
A working smoke detector and carbon monoxide detector in the basement
and on each level
Yes
No
A stove or microwave and refrigerator in working order
Yes
No
Meals and snacks for the children receiving care
Yes
No
A separate crib or playpen for each infant receiving care
Yes
No
A bed, sofa, cot, pad or mat for each toddler. preschooler or school age child who rests
Yes
No
Evidence of laboratory approval of your water supply (for nonpublic water systems only)
Yes
No
DATE
An approved, portable fire extinguisher
Yes
No
Childproof protective covers for electrical outlets
Yes
No
A smoke-free environment
Yes
No
Information necessary to perform a BCII and an FBI criminal records check on you, other
adult residents in your home, emergency/substitute caregivers and employees
Yes
No
Information necessary for the PCSA to conduct an abuse and neglect registry search on
you and other adult residents in your home
Yes
No
JFS 01643 (Rev. 1/2014)
Page 3 of 4
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