Application For A Preschool License - Nebraska Dhhs/division Of Public Health 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 preschool 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 preschool 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 Appplications 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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