Application For A Child Care License Form Page 2
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1
2F
DCDEE U
O
OR
SE
NLY
07/13
ID#
D
C
D
E
E
IVISION OF
HILD
EVELOPMENT AND
ARLY
DUCATION
C
N
.
OUNTY
O
– F
A
P
(
)
P
______
______
PPLICATION
ACILITY
ROFILE
CONTINUED
AGE
OF
Type of Business Operation
Check only one box:
Sole Proprietorship: A business owned and operated by one person for profit
General Partnership: Two or more people who carry on a business as co-owners for profit.
Limited Partnership: Consists of two or more people who jointly own or operate a business for profit. It is
similar to a general partnership except that one or more partners have limited liability and no rights to
management. A limited partnership must have at least one general partner.
Limited Liability Company: A business entity created by Statute. Owners are called members. One or
more members are required to organize a limited liability company. Management of the business of the
Limited Liability Company is vested in its managers.
Corporation: An organization formed under state or federal law. It is an artificial entity legally separated
from its owners.
Non-Profit Corporation: A corporation intended to have no income or intended to have income, none of
which is distributable to its members, directors, or officers.
Government: A program operated by city, county, state, or a federal entity.
H
,
,
?
AVE YOU
OR ANY OTHER PERSON LISTED ON THIS APPLICATION
PREVIOUSLY OPERATED A CHILD CARE FACILITY
Yes No This applies to any child care facility in the US, including military installations.
If yes, list facility name, ID# and location: _______________________________________________________
D
?
O YOU CURRENTLY HAVE A CHILD CARE LICENSE FOR ANOTHER LOCATION
Yes No
If yes, list facility name, ID# and location: _______________________________________________________
I
,
,
I
(
):
ATTEST
UNDER PENALTY OF PERJURY
THAT
AM
CHECK ONE OF THE FOLLOWING
A citizen of the United States
A non-citizen national of the United States
A lawful permanent resident (Alien #________________________)
An alien authorized to work (Alien # or Admission #) ___________________________ until (expiration date if applicable)
Other, please explain____________________________________________________________
Proof of residency must be verified by providing documentation such as a birth certificate, U.S. passport, Certificate of
Naturalization, or U.S. Citizen Identification Card.
I hereby certify that I do not habitually use alcoholic beverages to excess nor use illegal narcotics or other
impairing drugs I certify that I have given true, accurate and complete information on this form to the best of my
knowledge and I authorize investigation of all statements made on this form. I understand that failure to provide
true accurate and complete information may result in denial, revocation, or summary suspension of my license.
_____________________________________________________________________________
Signature of Applicant
Date
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