Form Dphhs-Qad/ccl-035a Renewal Application For Licensed Child Care Centers Page 2
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2CHILD CARE STAFF - Please complete Staff Master List and Employee Cover Sheets.
SWORN STATEMENT
In Accordance with Section 52-2-701 through 52-2-741, Montana Code Annotated, I hereby request the
issuance of a Day Care Center License on the basis of my affirmation of the following statements:
Please
Initial
a. I have received and have read a copy of the State Regulations for Day Care Centers that include the
supplemental regulations for Infant Care.
b. I certify that I intend to remain in compliance with the licensing requirements for day care centers.
c. I understand that I may not care for more children at any one time than are indicated by the day care
license.
d. I understand that any complaints about my licensed day care center may be investigated by a
representative of the Department, without prior notification.
e. I understand that my day care center may be visited at any time by the parent(s) or a child in care or
by a representative of the Department, and I will allow entry.
f. If I move to another address or stop providing care to children I must notify the Department of Public
Health and Human Services, Child Care Licensing Program.
g. I understand that the name and address of my day care center will appear on a list that is maintained
by the Department of Public Health and Human Services and made available to the public upon
request.
h. I will keep the necessary Insurance in force covering the total number of children I am caring for. I
certify that I have adequate Public Liability and Fire Insurance for the purpose of conducting child
day care. Please provide us with the name of your insurance company, the contact person,
policy number, effective dates, and number of children, coverage is provided for, by completing
the “Insurance Verification Form”. If you are renting, we need a copy of your landlord’s Fire
Insurance.
i. I will provide the department with the names, addresses, phone numbers, and parents’ names for each
child in my care whenever requested to do so by the department.
To the best of my knowledge and belief, all information I have given to the Department of Public Health and
Human Services and/or its authorized agents on this form is true and correct. I will supply true and correct
information requested during all subsequent contacts.
___________________________________
_____________
(Signature)
(Date)
TO BE COMPLETED BY A NOTARY PUBLIC:
Taken, Sworn, and subscribed before me, this ___________ day of ____________ A.D. ________
_____________________________________
(Notary Public for the State of Montana)
Residing at ____________________________
My Commission Expires _________________
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