Minnesota Department Of Human Services Application For Family Child
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FILLABLE FORM
Human Services
Minnesota Department of
d h S - 3 3 2 4 - e n g 4 - 0 8
Division of Licensing - Family Systems Unit
Application for Family Child Care (FCC), Child Foster Care (CFC),
Adult Foster Care (AFC) and Family Adult Day Services (FADS) licensure
Instruction:
* Indicates required sections
Use ink and print clearly.
New license: Complete all sections.
Dual licenses: Complete one application form for each program as needed.
Renew license: Complete sections 1, 2a, 3,5, 6, 8, 9,and any changes in sections 2, 4 and 7.
Change of premise: (Remaining with same licensing agency):
Update license: Complete sections 1,2, 2a, 3, 5, 6, 8, 9 and any changes in sections 2, 4 and 7.
Use existing license number at new address.
Close license: Complete sections 1, 3 and 9.
Change of name: Follow instructions for update.
1. Action code*
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License number* (if known) _____________________________________
Rule*
CFC
FCC
AFC
FADS
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Dual license (requires a variance request and DHS-3324 forms)
Action type*
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Yes
No
New
Close
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CFC
FCC
AFC
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Renew
Date:
______ _____ _____
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Update (Highlight changes made)
Code: __________
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Ownership type:
Change of premise _________________
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Individual(s) - The home is the primary residence of the license holder.
Corporate - The home is NOT the primary residence of the license holder.
2. Provider information
(corporation, business entity, owner,
3. Facility information*
(site where the services are provided)
managerial official or controlling individual)
Company name
gendeR
d.o.b.
(if corporate, list company name)
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name (LaST, FIRST, mI): pRInT CLeaRLy
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F
gendeR
d.o.b.
name (LaST, FIRST, mI): pRInT CLeaRLy
gendeR
d.o.b.
Print clearly (managerial or controlling individual)
name (LaST, FIRST, mI):
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M
F
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STReeT addReSS
STReeT addReSS
CITy
STaTe
ZIp Code (9 dIgIT)
CITy
STaTe
ZIp Code (9 dIgIT)
CounTy
pRovIdeR aRea Code and phone numbeR
CounTy
aRea Code and phone numbeR
2a. For child foster care only - provider race and ethnicity
Provider 1 Name____________________________ Provider 2 Name____________________________
Provider 3 Name____________________________
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African American/
Native Hawaiian or
African American/
Native Hawaiian or
African American/
Native Hawaiian or
Black
other Pacific Islander
Black
other Pacific Islander
Black
other Pacific Islander
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Alaska Native/
Two or more races
Alaska Native/
Two or more races
Alaska Native/
Two or more races
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American Indian
Unknown
American Indian
Unknown
American Indian
Unknown
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Asian
White
Asian
White
Asian
White
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Hispanic
Other
Hispanic
Other
Hispanic
Other
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