Child Day Care - Staff Application Fee Form Page 2
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12Child Day Care – Staff Application Fee Form
The licensing fee along with this Staff Application Fee Invoice Form is due with your application to
obtain a Family Day Care Home Staff Approval. THE FEE of fifteen $15.00 IS NON-REFUNDABLE.
Please complete items 1 through 9 of this form. If you have questions, call the licensing office at
1-800-282-6063 or (860) 509-8045. Make your payment by check or money order payable to:
TREASURER-STATE OF CONNECTICUT. Mail this form along with your payment and
application to the Office of Early Childhood at the address on the bottom of this form.
1. Name:__________________________________________________________________________
2. Address:______________________________________ ________________________, CT ______
Street
City/Town
Zip Code
3. Mailing Address (if different):
________________________________________ _________________________, CT __________
Street Address
City/Town
Zip Code
4. Home Phone Number: (_____)_______ -_______Cell Phone Number: (_____) ________ -_______
5. E-mail Address: _______________________ 6.ExpirationDate:____________________________
(for renewals only)
7. Enclosed Check/Money Order: $____________ Check #: _________Check Date_____/_____/____
8.
Social Security # : ________ - ________ - _________
(3 digits)
(2 digits)
(4 digits)
9.
Payment is for the following type of approval: (check one box below)
Family Day Care Home Staff Assistant
Family Day Care Home Staff Substitute
(Account #42431)
(Account #42431)
2-year approval (new)
2-year approval (new)
$15.00
$15.00
2-year approval (renewal)
2-year approval (renewal)
$15.00
$15.00
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