Fillable Application For A Child Care Center License Form

OWNERSHIP INFORMATIONATION AND REQUIREMENTS

1. Business Ownership: Check the appropriate box.

2. Business Ownership Name: Enter the information listed below, associated with the box checked in number 1.



Individual(s), enter your legal name(s): Last, First, Middle Initial



Partnership, enter ALL partners legal names: Last, First, Middle Initial



Limited Liability Company (LLC), enter the legal name of the LLC.



Corporation, enter the legal name of the corporation

3. Authorized Agent(s): The full legal name and title of person(s) designated by the Business Ownership to sign

Amendment Applications and other Licensing Documents.

4. Federal Identification Number: If no Federal ID Number, indicate “none.” The number will not be used

without consent except as required by law.

5. Secretary of State Number: If you are a Limited Liability Company or Corporation, you must apply to the

Nebraska Secretary of State for this number.

6. Mailing Address IF different than in #12 on Page 1: Indicate the mailing address if it is different than in

#12 on Page 1. When both addresses are the same, indicate “same.”

7. Preferred Phone Number if different than in 5 on Page 1: Enter the phone number if different than in # 5

on Page 1. When both phone numbers are the same, indicate “same.”

8. Preferred Email Address if different than in # 6 on Page 1: Enter the email address if different than in #6

on Page 1. When both email addresses are the same, indicate “same.”

9. Has any entity identified as a Program Owner, or a member of an LLC or Corporation, listed in Item #2

on Page 2, ever applied for and received a child care/preschool license in Nebraska?: Individual Owner(s),

Partners, members of Limited Liability Companies and members of Corporations must report any previous

child care/preschool license history. This information is subject to verification.

10. If the Program is owned by an Individual Owner or Partnership Owner each owner must complete the

following: Each individual or partner must complete the LEGAL ATTESTATION on Page 3 of this

application to comply with Nebraska Revised Statutes 4-808 to 4-414 attesting to his/her lawful presence in the

United States. If more space is required to list Individuals/Partners, please add additional pages.

IF Program is owned by a Limited Liability Company or Corporation, continue to Certification and

Signature of Owner Section on Page 4: Read and complete the “Certification and Signature of Owners”

Section.

CERTIFICATIONS AND SIGNATURES OF OWNERS

Please read this section carefully before signing to ensure it is signed by ALL required parties.

Signing this application verifies that information provided is true and correct.

SUBMITTING APPLICATION, DOCUMENTATION, & FEES

OPTION 1: EMAIL: The completed application and the required additional documentation ONLY may be submitted to the Department by

scanning and emailing those documents to DHHS.ChildCareLicensing@nebraska.gov.

The required fee must be mailed separately via U.S. Mail, along with a copy of the front page of the application to the

appropriate address listed below in Option 2.

OPTION 2:

: The completed application, required additional documentation and fee may be mailed to:

U.S. Mail

Cass, Douglas, Sarpy & Washington Counties:

ALL Other Nebraska Counties:

DHHS/Division of Public Health

Office of Children’s Services Licensing

1313 Farnam Street, 3

Floor

P.O. Box 94986

Omaha, NE 68102

Lincoln, NE 68509-4986

Application For A Child Care Center License Form - Dhhs Page 2

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