Fillable Application For A Child Care Center License Form

Application For A Child Care Center License Form - Dhhs Page 4

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OWNERSHIP INFORMATION AND REQUIREMENTS

1. Business Ownership:

__Individual__Partnership__Limited Liability Company__Corporation

(Check one)

__District (i.e., school)__ Other (i.e., city, tribal)

2. Business Ownership Name:_______________________________________________________________

_______________________________________________________________

3. Authorized Agent(s):____________________________________________________________________

4. Federal Identification Number:_________________________

5. Secretary of State Number:____________________

(Limited Liability Company or Corporation ONLY)

6. Mailing Address IF different than in # 12 on Page 1:____________________________________________

______________________________________________________________________________________

7. Preferred Phone Number IF different than # 5 on Page 1: _______-______-_______

8. Preferred Email Address IF different than # 6 on Page 1:________________________________________

9. Has any entity identified as a Program Owner in Item #2 above ever applied for and received a child

care/preschool license in Nebraska? __YES __NO IF Yes, identify the individuals and the name and

address of EACH Program: _________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________

10. IF the Program is owned by an INDIVIDUAL OR PARTNERSHIP each owner must complete the following

Legal Attestation section on Page 3 of this application: (If more than 3 partners, please add additional pages.)

→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→

IF Program is owned by a LIMITED LIABILITY COMPANY OR CORPORATION continue to

Certification and Signature of Owner(s) Section on Page 4. →→→→→→→→→→→→→→→→→→

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Application For A Child Care Center License Form - Dhhs Page 4

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