Application Form & Full Disclosure Of Ownership Statement For An Amended License By A Non-Profit Corporation Or Governmental Unit

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Division of Public Health–Licensure Unit–Children's Services Licensing
Application & Full Disclosure of Ownership Statement for an Amended License
by a Non-Profit Corporation or Governmental Unit
READ CAREFULLY, USE BLACK INK, PRINT LEGIBLY AND FOLLOW ENCLOSED INSTRUCTIONS
LICENSE TYPE: (CHECK ONE)
FAMILY CHILD CARE HOME II
CHILD CARE CENTER
SCHOOL-AGE-ONLY CENTER
PRESCHOOL
PROGRAM LICENSE NuMbER __________________________________________
THIS APPLICATION MuST bE SIGNED AND DATED
TYPE OF AMENDMENT
Check all that apply:
Change Licensed Days of Operation
Add:
Household Member
Staff
Substitute
Volunteer
Change Licensed Hours of Operation
Change License Capacity
List All Name(s) Added: __________________________________
Change Licensed Age Range
_______________________________________________________
Change/Add Space
_______________________________________________________
_______________________________________________________
Describe: ______________________________________________
_______________________________________________________
_______________________________________________________
Check all that apply:
Address Change – (provide new address below in Section A
number 2)
Remove:
Household Member
Staff
Substitute
Volunteer
Effective Move date: ___________________________________
List All Name(s) Removed: ________________________________
Preferred Mailing Address Change
_______________________________________________________
Add/Change Director
_______________________________________________________
Add/Change Primary Provider
_______________________________________________________
_______________________________________________________
Licensee's Name Change
Add Partner(s)
Program Name Change
Other: _______________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Complete all the following sections that are applicable to your facility. Refer to instructions for more detailed information.
SECTION A - IDENTIFYING INFORMATION
1.
Name of Program: ________________________________________________________________________________________________
2.
Physical Address of Program: __________________________________________________________
___________________________
(Street, City, Zip Code)
(County)
3.
Program Phone Number/Cell Phone with Area Code: ______________ 4. Fax Number with Area Code (if applicable): __________________
5.
Email (optional): _________________________________________________________________________________________________
6.
Director/Primary Provider: _________________________________________________________________________________________
(Name)
7.
License Capacity: ___________________ 8. Licensed Age Range: ________________ (wks, mos, yrs) to ________________ (mos, yrs)
9.
Licensed Hours of Operation (specify whether A.M. or P.M. hours): ______________ to ______________
OR
24 Hour Care
10. Licensed Days of Operation: (check all that apply):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
11. Preferred Mailing Address For Receipt Of Official Correspondence From The Department:
__________________________________________________________________________________________________________________
(PO Box, Street, City, Zip Code)
12. Person(s) within Corporation or Governmental Unit designated by the Owner to Sign Amendment Applications and other Licensing Documents.
________________________________________________________________________________________________________________________________________
(Name(s)
Title(s) (i.e., Authorized Agent/Representative, Director, or Administrator)
__________________________________________________________________________________________________________________
(Street, City, Zip Code)
Distribution: WHITE: Central Office; CANARY: Children's Services Licensing; PINK: Provider/Applicant
CRED-0956 (25023) 6/14
1

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