Application For Child Care Program/residential Child Care Program License Form printable pdf download

DEPARTMENT OF HEALTH & HUMAN SERVICES

APPLICATION FOR CHILD CARE PROGRAM/RESIDENTIAL CHILD CARE PROGRAM LICENSE

OFFICE OF OPERATIONS SUPPORT

LICENSING & REGULATION SERVICES

CHILD CARE LICENSING UNIT

FOR OFFICE USE ONLY

129 PLEASANT STREET, CONCORD, NH 03301

LICENSE NUMBER _________________________

PHONE: 603-271-9025 1-800-852-3345 EXTENSION 9025

NEW

REVISION

RENEWAL

CHECK TYPE OF APPLICATION:

REFER TO NH CHILD CARE PROGRAM LICENSING RULES, He-C 4002, AND RSA 170-E:2 (CHILD CARE) AND NH RESIDENTIAL CHILD CARE PROGRAM LICENSING

RULES, He-C 4001, AND RSA 170-E:25 (RESIDENTIAL CHILD CARE) FOR REQUIREMENTS FOR EACH PROGRAM TYPE BEFORE CHECKING PROGRAM TYPE BELOW.

CENTER BASED CHILD CARE

FAMILY BASED CHILD CARE

RESIDENTIAL CHILD CARE

INFANT/TODDLER PROGRAM

SCHOOL AGE PROGRAM

FAMILY CHILD CARE HOME

GROUP HOME

PRESCHOOL PROGRAM

NIGHT CARE PROGRAM

FAMILY GROUP CHILD CARE HOME

CHILD CARE INSTITUTION

GROUP CHILD CARE CENTER

NIGHT CARE PROGRAM

INDEPENDENT LIVING HOME

OTHER

PROGRAM NAME: ______________________________________________________________________________________________________

PHONE: ________________________

MAILING ADDRESS: _______________________________________________________________________________________________________________________________________

STREET

___________________________________________________________________________________________________________________________

CITY/TOWN

STATE

ZIP CODE

ACTUAL LOCATION ADDRESS: ____________________________________________________________________________________________________________________________

STREET

___________________________________________________________________________________________________________________________

CITY/TOWN

STATE

ZIP CODE

NAME OF APPLICANT/OWNER:

___________________________________________________________________________________________________________________________

MAILING ADDRESS:

___________________________________________________________________________________________________________________________

STREET

___________________________________________________________________________________________________________________________

CITY/TOWN

STATE

ZIP CODE

APPLICANT/OWNER'S PHONE NUMBER: _______________________________________________ E-MAIL ADDRESS IF AVAILABLE:____________________________________

: ________________________

SOCIAL SECURITY NUMBER IF APPLICANT IS AN INDIVIDUAL

FEDERAL TAX I.D. NUMBER IF ONE HAS BEEN ASSIGNED:_________________________________

NUMBER & AGE RANGE OF CHILDREN TO BE CARED FOR:

IF YOU WANT A SINGLE LICENSE TO INCLUDE MULTIPLE BUILDINGS (CHILD CARE PROGRAMS ON THE SAME OR CONTIGUOUS PROPERTY) (RESIDENTIAL FACILITIES

IN SAME GEOGRAPHICAL REGION), YOU MUST PROVIDE THE FOLLOWING FOR EACH BUILDING:

1. A MEANS BY WHICH WE CAN IDENTIFY THE BUILDING, I.E. BUILDING #1 & 2, FRONT BUILDING, BACK BUILDING OR, IF APPROPRIATE, THE NAME OF THE

BUILDING;

2. THE MAXIMUM NUMBER OF CHILDREN AND AGE RANGE THAT WILL BE CARED FOR IN THE BUILDING.

MAXIMUM

BUILDING IDENTIFIER

AGE RANGE TO BE CARED FOR IN EACH BUILDING

NUMBER

OF CHILDREN

FROM ________ YEARS ________ MONTHS TO ________ YEARS ________ MONTHS

MONTHS OF OPERATION: _________________________________________________________________________________________________________

DAYS OF OPERATION:

_________________________________________________________________________________________________________

OPERATING HOURS:

______________________________________________

FROM

RESIDENTIAL CHILD CARE PROGRAMS MUST COMPLETE THIS SECTION. CHILD CARE PROGRAMS MUST COMPLETE THIS SECTION IF THEY ARE INCORPORATED.

NAME OF CORPORATION: (IF INCORPORATED)

__________________________________________________________________________________________________________________________________________________________

NON PROFIT

FOR PROFIT

OFFICERS OF CORPORATION

NAME

TITLE/POSITION

TELEPHONE NUMBER

t:\program support\licensing\ccl\group\2008 cc rules\forms\2008 application.doc

Page 1 of 4

2008 APPLICATION 04/22/09