Application For A Family Child Care Home Ii License Page 6
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7CERTIFICATION AND SIGNATURES OF OWNERS
A list of complete names and addresses of all persons in control of the Family Child Care Home II 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 Family Child Care Home II 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
Page 4 of 4
FCCH II
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