Application Form & Full Disclosure Of Ownership Statement For An Amended License By A Non-Profit Corporation Or Governmental Unit Page 3

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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
SECTION C - FACILITY INFORMATION:
FOR FAMILY CHILD CARE HOME II, CHILD CARE CENTER, SCHOOL-AGE-ONLY CENTER OR PRESCHOOL:
Do you live on the premises?
Yes
No
Where is the program located?
House
School
Church
Free Standing
Strip Mall
Store Front
Other (Describe) ____________________________________________________________________
Do you own the property where the program is located?
Yes
No
If you rent or lease the property, give the name, address and phone number of the owner/landlord (landlord information may be verified):
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
SECTION D - HOuSEHOLD INFORMATION:
This section must be completed for ALL programs when the child care is located in a residence. You may copy this
page as needed.
List below ALL persons residing at the child care/preschool program address INCLuDING yourself, spouse, significant other, children,
grandchildren, foster children, relatives, roommates and any individual regularly present.
OTHER NAME/S uSED
RELATIONSHIP
LEGAL NAME
SOCIAL SECuRITY
bIRTH DATE
(maiden, alias, previosly married,
TO APPLICANT
NuMbER
MM/DD/YY
(last, first, middle initial)
nickname)
(i.e., son, daughter)
SECTION E - STAFF INFORMATION FOR FAMILY HOMES II ONLY:
List below ALL persons who are designated as: primary provider, staff substitute, or volunteer. You may copy this page
as needed.
bIRTH
WORK
OTHER NAME/S uSED
SOCIAL SECuRITY
FTE
LEGAL NAME
POSITION
DATE
SCHEDuLE
(maiden, alias, previously
(last, first, middle Initial)
(i.e., Staff)
NuMbER
PTE
married, nickname)
MM/DD/YY
(i.e., Hours Days)
Distribution: WHITE: Central Office; CANARY: Children's Services Licensing; PINK: Provider/Applicant
CRED-0956 (25023) 6/14
3

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