Application For A Family Child Care Home Ii License Page 4
Download a blank fillable Application For A Family Child Care Home Ii License in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For A Family Child Care Home Ii License with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
715. Will the Family Child Care Home II be located in a private residence? __YES __NO
IF YES, provide the following information for ALL persons residing at the family child care home address INCLUDING
yourself, spouse, significant other, children, grandchildren, any other person.
LEGAL NAME
OTHER NAMES USED
SOCIAL SECURITY
BIRTH DATE
RELATIONSHIP TO
NUMBER
APPLICANT
(Last, First, Middle Initial)
(maiden, alias, nickname )
(MM/DD/YY)
(i.e., son, daughter)
OWNERSHIP INFORMATION AND REQUIREMENTS
1. Business Ownership:
__Individual__Partnership__Limited Liability Company__Corporation
(Check one)
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. →→→→→→→→→→→→→→→→→→
Page 2 of 4
FCCH II
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal