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2. State License Type*

   1. Adult Day Program
   2. Childcare

   1. Home Care Agency
   2. Other
3. License Status*
   -- Select One --New LicenseRenew Existing LicenseModify Existing License
5. Business/Facility Information
7. Business/Facility Name (DBA)*
8. Business Phone*
10. Address to Be Inspected*
11. Unit*
13. City*
14. County*
16. Monitored Fire Alarm Installed?*

    1. Yes

    1. No
17. Automatic Fire Sprinklers Installed?*

    1. Yes

    1. No
19. How many care recipients are you requesting to have?*
20. Care Recipient Age Range*
    -- Select One --Under 2 1/2 Years Old2 1/2 Years to 18 Years OldOver 18 Years Old
22. Contact Information
24. Business Owner or Director’s Name*
26. Business Owner or Director’s Phone*
27. Business Owner or Director’s Email*
29. State Licensing Agent Name*
31. State Licensing Agent Phone*
32. State Licensing Agent Email*
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field