License Modification Request For Facility Change Of Location Form
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1VIRGINIA DEPARTMENT OF SOCIAL SERVICES
DIVISION OF LICENSING PROGRAMS
LICENSE MODIFICATION REQUEST FOR FACILITY CHANGE OF LOCATION
Instructions: To ensure timely processing, the licensee must submit a modification request to the area Licensing
Office at least 60 days prior to the facility’s planned change of location.
Licensee: __________________________________________
___________________________________________
Printed Name
Signature
Licensee Email:________________________________ License Number
(located on bottom left of license)____________________
Facility Name: ____________________________________________________________________________________
Planned Date of Relocation: _________________________________________________________________________
OLD Physical Address: _____________________________________________________________________________
Street
City
State
Zip
OLD Mailing Address: ______________________________________________________________________________
Street
City
State
Zip
NEW Physical Address: _____________________________________________________________________________
Street
City
State
Zip
NEW Mailing Address: _____________________________________________________________________________
Street
City
State
Zip
OLD Telephone Number: ___________________________ NEW Telephone Number: _______________________
DIRECTIONS TO NEW LOCATION: ________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
All licensees except child-placing agencies and family day systems must submit the following to the Licensing
Office regarding the new location:
______ A copy of the fire inspection, if required by program standards;
______ A copy of the Report of Environmental Sanitation Inspection, if required by program standards;
______ The Building Evaluation or Inspection form, if required by program standards;
______ A floor plan, if required by program standards;
______ A site plan, if required by program standards;
______ An asbestos statement, for any child day center building built prior to 1978;
______ Verification of liability insurance, if required by program standards; and
______ For family day homes, Contact with Local Zoning Administrator form (for new site).
For child placing agencies only: Provide verification of applicable office setting and condition requirements by standards.
032-05-0850-01-eng (Revised 10/14)
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