Child Care Provider Application Purpose Cover Letter
[Pages:1]Child Care Provider Application Purpose Cover Letter
Submitted Application Number: ___________________
Personal/Facility Information: Name of Applying Individual: First Name: _______________________ Last Name: _______________________
Business Name (if different than the name of the individual above): _______________________________________________________
Facility Name: ___________________________________________ Certificate Number (if existing): _____________________________ Facility Address Line 1: ____________________________________ Facility Address Line 2: ____________________________________ City: _________________________ State: _________________________ Zip: _________________________ County: _________________________
Application Purpose: Please select the purpose of submitting your application from the list below:
Open/Operate a New Facility Renew Facility Certification Change of Ownership of Business Change of Facility Location Change of Facility Name Change of Business Name
Change of Facility Post Office Address Change of Profit/Nonprofit Status Increase/Decrease of Facility Capacity Change in Name of Owner/Operator Close Existing Facility
Supporting Documentation: Please select all supporting documentation being submitted:
Criminal Record Check - SP-4-164
Certificate of Authority
Child Abuse Clearance - CY-113
Tax Form
Staff Health Appraisal - CY-322
Proof of Registration
BEO Compliance Letter
Verification of Compliance
Proof of Nonprofit Status
Articles of Incorporation
Fictitious Name Approval
Certificate of Occupancy
Letter Confirming Voluntary Closure - Family Child Care Home
Letter Confirming Voluntary Closure - Child Care Center or Group Child Care
Home
Post Office Letter for Change of Address issued by the Post Office
Signature: ______________________________ Date: ___________
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