Fillable Application For A Child Care Center License Form

Application For A Child Care Center License Form - Dhhs Page 6

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CERTIFICATION AND SIGNATURES OF OWNERS

A list of complete names and addresses of all persons in control of the child care center program must be included

on the application. This list must include all individual owners, partners, limited liability company members,

parent companies, if any, and members of boards of directors owning or managing the corporations and any other

persons with financial interests or investments in the child care center program. In the case of publicly held

corporations, the individual owners listed must include any stockholders who own 5% or more of the company’s

stock.

All Applications must be signed by:

 The owner, when the applicant is an Individual Owner;

 All owners, when the applicants are a Partnership;

 Two members, when the applicant is a Limited Liability Company(One signature will be accepted if the

LLC is a one member company.)

 Two officers that have authority to bind the Corporation to the terms of the application, when the

applicant is a corporation. However, one signature will be accepted if the articles of incorporation are

submitted with the application.

I/We have read the Rules and Regulations issued by the Nebraska Department of Health and Human Services-

Division of Public Health-Licensure Unit-Office of Children’s Services Licensing and will comply should a

license be issued. I/We have fully disclosed all owners of the program regardless of whether an owner particpates

in the operation of the program. I/We certify to the best of my/our knowledge that the information provided on

this application is true and correct.

______________________________________

_______________________________

________________

Print Name and Title

Signature

Date

______________________________________

_______________________________

________________

Print Name and Title

Signature

Date

______________________________________

_______________________________

________________

Print Name and Title

Signature

Date

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Application For A Child Care Center License Form - Dhhs Page 6

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