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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