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NO'TCE TO APPLTCAV^^ <br />PU«s« r«*d ch« following Ir.formaclon. sign the fora btlow and return with <br />your application for licenaura. <br />* Under no circuaatancai will the Deparcaenc of Human Services issue a <br />license dated prior to the completion of the licensing study. <br />* * Under Minnesota Statutes, Chapter 245A.04. the Department of Human <br />Services (DHS) has 90 working days after receipt of a. eomplece enolleacinn co <br />conduct a licensing study end act on the application. A complete eppUcation <br />includes all req«*.ired reports for DHS and from other state agencies or <br />departments, counties, municipalities, or ocher political subdivisions. <br />* * Under Minnesota Statutes, Chapter 245A.03, subdivision 3, it is a <br />misdemeanor to provide a program chat is subject to licensure without a <br />license. <br />1 have read and I understand the conditions stated above. <br />Mama of Applicant (Legally ftasponsible Party) <br />Name of Program <br />Address <br />Signature of Applicant <br />Data