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License Number <br />1. Issued to: <br />Applicant Information <br />Renew <br />O^S jcvi <br />1 New <br />(Number timj^ned by DHS) <br />(Name of Corpora uon. Partncrrahip, Govemmenl L*nii) <br />Address:. <br />City:___Zip:.County:. <br />2. <br />3. <br />Facility known aa: <br />Addreu: <br />City: <br />Director of facility: <br />Mailing label requested License should be sent to the address listed below: <br />Name: <br />Phone: <br />Address:. <br />City:___ <br />4. b„kp«„„d .tud, maiUn, .ddr...: (Addr.,, wh„. program prafar. m raaaiv. privau or aani«va i„f,n„.d„n) <br />Individual___ <br />Program name <br />Address; <br />Check here if additional ABS forms are needed. How many?___ <br />For Licensor use only: Licensing Instruction Form <br />Rule # <br />Indicate change. <br />—1 Provisional: Prom <br />Renewal: Prom to <br />—Probationary/Mail Certified <br />—Change in licensure <br />Reprint License <br />Extension Date Tot. <br />Closed <br />Gosing Date: ____ <br />Catesrnrv Brealcfl <br />Rules Total Capacity: <br />Months <br />Full Half <br />Days of Weak. <br />J Drop-in JSick <br />Year Round Hours <br />Night <br />Infants Toddlers <br />Not to exceed: <br />Preschool _ School-agai <br />Role 4 Focter Care Adoption I—I Foster Care and Adoption <br />Reaidentukl/Noiureeidential} <br />Total Capadtv: <br />Sex: M P MF <br />_ No more than <br />Category I Category II <br />on sdb# Age: Prom <br />Category III <br />_ through _ <br />Category IV <br />Rule 42 To provide rssid.ntial-baaed hahil tation services in County # <br />rWork«r Co4^h________ <br />DaU: <br />Additional Commanta: