Application For A Child Care Center License Form - Dhhs Page 3
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7FOR OFFICE USEONLY
Check/Money Order
#_____________________
APPLICATION CHILD CARE CENTER
PLEASE READ CAREFULLY, TYPE OR PRINT LEGIBLY
PROGRAM INFORMATION
1.
Type of License: (Check one) __Provisional __Operating-Current License Number: CCC__________
2.
Name of Child Care Center:________________________________________________________________________
3.
Physical Address of Child Care Center:_______________________________________________________________
(
County:__________________________
Street, City, Zip Code)
4.
Type of Structure: (Check one) __Church __School__Other________________________________________
5.
Phone/Fax Number of Center, including area code: ______-______-_______Fax Number: ______-______-_______
6.
Email Address of Child Care Center: ________________________________________________________________
7.
Name of Child Care Center Director:_________________________________________________________________
8.
Requested Licensed Capacity of Child Care Center:________
9.
Age Range of Children to be Served by Child Care Center: FROM: _______________ TO: _______________
Circle one (weeks, months, years)
Circle one ( months, years)
10.
Hours of Operation: (Specify a.m. or p.m.) FROM: _________ TO: _________ OR __24 Hour Care
11.
Days of Operation:(Check all that apply):__
Monday__Tuesday__Wednesday__Thursday__Friday__Saturday__Sunday
12.
Preferred Mailing Address:_________________________________________________________________
)
(
P.O. Box, Street, City, State, Zip Code
13
. Child Care Subsidy (choose one): __Accept subsidy.
__Currently do not accept subsidy, but willing to in the future.
__Do not accept subsidy.
14. Will the Child Care Center be located in a private residence? __YES __NO
IF No, Continue on to Page 2 of the application.→→→→→→→→→→→→→→→→→→→→→→→→→→→
IF Yes, provide the following Information for ALL persons residing at the child care center program
address INCLUDING yourself, spouse, significant other, children, grandchildren, any other person.
LEGAL NAME
OTHER NAMES
SOCIAL SECURITY
BIRTH DATE
RELATIONSHIP TO
USED (maiden, alias)
NUMBER
APPLICANT
Month/Day/Year
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