Application For A Preschool License - Nebraska Dhhs/division Of Public Health Page 3
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7FOR OFFICE USEONLY
Check/Money Order
#_____________________
APPLICATION PRESCHOOL
PLEASE READ CAREFULLY, TYPE OR PRINT LEGIBLY
PROGRAM INFORMATION
1.
Type of License: (Check one) __Provisional __Operating-Current License Number: PRE_________
2.
Name of Preschool:____________________________________________________________________________
3.
Physical Address of Preschool:___________________________________________________________________
(
County:_____________________
Street, City, Zip Code)
4.
Type of Structure: (Check one) __Church __School__Other________________________________________
5.
Phone/Fax Number of Preschool, including area code: _____-_____-______ Fax Number: _____-_____-_______
6.
Email Address of Preschool: ________________________________________________________________
7.
Name of Preschool Director:________________________________________________________________
8.
Requested Licensed Capacity of Preschool:________
9.
Age Range of Children to be Served by Preschool: FROM: _______________ TO: _______________
(years)
(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. Will the Preschool 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 preschool 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
Month/Day/Year
APPLICANT
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