Home Child Care Facility Application Form - Fairfax County, Virginia Page 2
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2Home Child Care Facility Application
SECTION D-Criminal History Records
Complete all information listed below for all adults (18 years and older) living at home, including the
applicant and all substitute care providers. (Indicate N/A, if not applicable) A processing fee of $15.00 must
accompany each person’s name listed below. The information you provide will be forwarded to the Virginia
State Police in Richmond who will perform a search of Criminal History Records.
1.__________________________ _______________________
_______________
______
_____ _________
Last
First
Middle
Sex
Race
Birth Date
___________________________________________________
Maiden Name
2.__________________________ _______________________
_______________
______
_____ _________
Last
First
Middle
Sex
Race
Birth Date
___________________________________________________
Maiden Name
3.__________________________ _______________________
_______________
______
_____ _________
Last
First
Middle
Sex
Race
Birth Date
___________________________________________________
Maiden Name
4.__________________________ _______________________
_______________
______
_____ _________
Last
First
Middle
Sex
Race
Birth Date
___________________________________________________
Maiden Name
5.__________________________ _______________________
_______________
______
_____ _________
Last
First
Middle
Sex
Race
Birth Date
___________________________________________________
Maiden Name
I am submitting this application for a permit to operate a home child care facility at the address listed
in Section A. By making this application, I give permission for the County to inspect that property in
order to determine compliance with Chapter 30 of the Fairfax County Code. Also by making this
application, I agree to comply with the provisions of the County Code that relates to home child care
facilities.
SECTION E
Applicant Signature________________________________________________
Date____________________________________
The maximum number of non-resident children you may care for at any one time is 4.
Revised 6/16
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