Child Day Care - Staff Application Fee Form (Page 6 of 12) in pdf

Child Day Care - Staff Application Fee Form Page 6

CONNECTICUT OFFICE OF EARLY CHILDHOOD

Division of Licensing

STATEMENT OF COMPLIANCE

Applicant’s Name: _____________________

____________________ _______________________________

First

Middle

Last

Address of Facility: ___________________________ _______________________ _______ _________________

Street

Town

State

Zip

I certify that I have read and understand the regulations for the licensure of family day care homes adopted by

the Commissioner of the Office of Early Childhood pursuant to Connecticut General Statutes Section 19a-87b(f).

I am currently in compliance with, and will maintain my family day care home in compliance with these

regulations, and I will allow home visits by Agency staff to the family day care home.

I certify that all children enrolled in the family day care home have received age-appropriate immunizations in

accordance with Section 19a-87b-10(k) of the regulations for the licensure of family day care homes.

NOTICE OF PENALTY FOR FALSE STATEMENTS

Under the law, all information provided on this application form, or in any statements accompanying this application, must be

truthful. Any false statements could cause the denial of this application and may be punished as a Class A Misdemeanor under

Section 53a-157b of the Penal Code. This notice is given as required by the Connecticut General Statutes, Section 19a-87b(a).

Understanding the penalties for false statements, I attest that my statements in this application are true, to the best of my

knowledge and belief.

X___________________________________________

_______________________________

(Signature of Applicant)

(Date)

Child Day Care - Staff Application Fee Form Page 6