COMMUNITY CARE LICENSING APPLICATION FOR …

STATE OF california - HEALTH AND HUMAN services AGENCYCALIFORNIA department OF social SERVICESCOMMUNITY care LICENSINGAPPLICATION FOR A FAMILY child care HOME LICENSEType or print clearly. USE ONLYNUMBER:TYPE:TYPE OF LICENSE:LICENSE #: LICENSING AGENCY:ADDRESS:PHONE:PHONE:CITYSTATEZIPC ITYCOUNTYSTATEZIPCITY STATE ZIPDATE LICENSED/CERTIFIED:ASSIGN:APPLICANT(S) FirstMiddleFirst NameMiddleApplicant(s) SignaturesCity and County where SignedDateLast NameRelationship to YouLast NameOver 18 Years Old? TYPE OF APPLICATION New APPLICATION Capacity Change Location Change Update6. ARE YOU CURRENTLY, OR HAVE YOU EVER BEEN, LICENSED OR CERTIFIED FOR ANY TYPE OFFACILITY TO care FOR CHILDREN OR ADULTS? HOME ADDRESS:3b. IF YOU HAVE NOT LIVED IN THIS COUNTY FOR THE PAST TWO YEARS, LISTTHE COUNTIES IN WHICH YOU HAVE (S) TO ADDRESS (if different):AGES TO BE SERVED:DAYS & HOURS OPEN:LIC 279 (2/09) PAGE 1 OF 2 ADULTS IN THE HOME (Not applicant(s)) Do not list the names of persons under 18 years of OF LICENSE Small Home (up to 8) Large Home (up to 14)10.

state of california - health and human services agency california department of social services community care licensing application for a family child care home license

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  Social, Services, Department, Applications, Care, Community, California, Child, Licensing, Child care, Community care licensing application, California department of social services community care licensing application

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