Application To Operate A Child Care Facility Form - Palm Beach County Child Care Facilities Board
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2RENEWAL
PALM BEACH COUNTY CHILD CARE FACILITIES BOARD
FLORIDA DEPARTMENT OF HEALTH - PALM BEACH COUNTY
800 Clematis Street, West Palm Beach, FL 33401
APPLICATION TO OPERATE A CHILD CARE FACILITY
Note: All information on this application must be truthful and correct. This 2-page application must be completed in its
entirety. An incomplete application will not be accepted. Please contact this office if there are any questions about
completing this application. All unpaid administrative fines must be paid before your license can be renewed.
Application Date: ______/_____/_________
I. FACILITY INFORMATION
Name of Facility: ________________________________________________________________________________
Address of Facility: ______________________________________________________________________________
_______________________________________________________________________________
Phone: (______) _______________________
Fax: (______) _______________________
1. Number of children under age 2 enrolled at the facility _______
2. Number of children age 2 and older enrolled at the facility ________
3. Total capacity of facility _________
II. OWNER OF BUSINESS:
Name: ________________________________________________________________________________________
Address: ______________________________________________________________________________________
Phone: (____) ____________
III OWNER OF REAL PROPERTY
Legal Name: __________________________________________________________________________________
Address: _____________________________________________________________________________________
ON-SITE DIRECTOR INFORMATION
Name of Director: ______________________________________ ___________________________
Date of Birth: ______________________
First
Middle (Maiden)
Last
Director’s Home Address: ____________________________________________________________________________
Zip Code: ________________
(Street or P.O. Box)
City
Telephone Number: (________) _________________________
Director Credential Certificate Number: ________________________ Director Credential Level: __________________ Certificate Expiration Date: _____________
Page 1 of 2
Revised 8/2015
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