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Renewal Application For Child Care Facility License - Nevada

Renewal Application For Child Care Facility License Form. This is a Nevada form and can be used in Adoption Division Of Child And Family Services Statewide .
 Fillable pdf Last Modified 7/7/2011
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STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES CHILD CARE LICENSING LAS VEGAS OFFICE 3811 W. Charleston Blvd Ste 210 Las Vegas, Nevada 89102 Phone: 702-486-3822 Fax: 702-486-6660 ELKO OFFICE 1010 Ruby Vista Drive Suite, 101 Elko, Nevada 89801 Phone: 775-753-1237 Fax: 775-753-1336 CARSON CITY OFFICE 727 Fairview Drive, Suite E Carson City, Nevada 89701 Phone: 775-684-4463 Fax: 775-684-4464 RENEWAL APPLICATION FOR CHILD CARE FACILITY LICENSE All applications must be complete, signed and returned to the appropriate office referenced above. Any application that is incomplete and/or not signed will be returned without processing. LICENSES ARE NOT TRANSFERABLE FROM ONE OWNER TO ANOTHER AND ARE VALID ONLY FOR THE PREMISES DESCRIBED ON THE LICENSE. 1. IDENTIFYING INFORMATION: Owner: ___________________________________________________________________________________________________ Child Care Facility: _________________________________________________________________________________________ Physical Address: _______________________________________City:________________________ State: ______ Zip: __________ Mailing Address if different from physical address: ________________________________________________________________ Telephone: __________________________Fax: _______________________Email: _____________________________________ Corporate Office: _________________________City: _______________________State: ______________Zip: ____ ___________ Corporate Contact Person: ____________________________________________________________________________________ Telephone: _______________________ Fax: ______________________Email: _______________ Citizenship: ______________________ If not U.S., provide explanation: __________________________________________________________________________________________________________ 2. ACTION REQUESTED: RENWAL APPLICATION/LICENSE TYPE OF FACILITY Check all that apply Number of requested spaces for children: Ages of children: Center Center _____ ___ to ___ Nursery for Infants & Toddlers Nursery (Under 2 years.) _____ ___ to ___ Additional Before & After School 3 slots or 10% _____ ___ to ___ (If approved) Care for Ill Children(CIC) CIC _____ ___ to ___ Accommodation Accommodation _____ ___ to ___ Designated Operator-Name_________________________________________________________________________ Extended Accommodation Extended Accommodation _____ ___ to ___ Designated Operator -Name_________________________________________________________________________ Institution Type Residential Educational Shelter Care _____ ___ to ___ Special Event Special Event _____ ___ to ___ Other Other _____ ___ to ___ Director Application(s): Check all that apply AND insert all names. Submitted for: Name: Facility Director ______________________________________________________________________ Infant Toddler Nursery ______________________________________________________________________ Care for Ill Children ______________________________________________________________________ Preschool ______________________________________________________________________ Institution ______________________________________________________________________ 3. OWNERSHIP: Check one Individual proprietorship: (Identify owner name, address, and persons having ownership of 10% or more.) Corporation: (Identify Corporation name, address; officers by name, title, address and telephone number.) Partnership: (Identify each partner by name, address and telephone number.) Other: (Describe the ownership arrangement and identify the owner(s) by name, address and telephone number.) (If incorporated, date of incorporation __________ in the State of _______ and operated for Profit Non-profit) ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ American LegalNet, Inc. Revised 07/13 Provide the and percentage of stock, shares, partnership or other equity interest of each officer, member of the board of directors, trustees, stockholders, partners, or other persons who have greater than 25 percent interest in the facility: Last Name First Name Middle Date of Birth SSN Address Telephone % Interest 4. BACKGROUND CHECKS: Each of the persons listed in this application have attested to the applicant that they have no pending charges and: a) Have never been convicted of a felony; b) Have never been in violation of any federal or state law regulating child abuse and/or neglect or contributory delinquency; c) Have never been in violation of any federal or state law regulating the possession, distribution or use of any controlled substance or any dangerous drugs as defined in chapter 454 of NRS; d) Have never been in violation of any federal or state law regarding murder, manslaughter or mayhem; any other violation involving the use of a firearm or other deadly weapon; assault with intent to kill or to commit sexual assault or mayhem; sexual assault, statutory sexual seduction, incest, lewdness, indecent exposure or any other sexually related crime; e) Have never been found in violation of any local, state or federal law which arises from or is otherwise related to the individual's relationship to a child care facility; f) Have not currently or in the past had previous interest in a licensed child care facility that has been any of the following: (i) Closed as a result of a license suspension or revocation; (ii) Involuntarily terminated for any reason; or (iii) Convicted of child abuse, neglect or exploitation. g) Convicted of any other crime involving physical harm to a person or if a criminal action is pending against the person. IF YOU AS THE APPLICANT, OWNER(S), OPERATOR(S), BOARD MEMBERS, VOLUNTEERS OR STAFF MEMBERS HAVE EVER BEEN ARRESTED OR CONVICTED OF ANY CRIMES, IDENTIFY THE PERSON BY NAME, RELATIONSHIP, BIRTH DATE, CRIME, STATE OF ARREST OR CONVICTION, DATE OF ARREST OR CONVICTION AND DISPOSITION OF ARREST(S). (All must be included regardless of the year occurred.) State of Arrest/ Date of Arrest/ Name Relationship Birth Crime Conviction Conviction Disposition FINGERPRINTS HAVE BEEN SUBMITTED IN NEVADA FOR ALL PERSONS INCLUDED IN THIS APPLICATION: YES NO If no, explain:__________________________________________________________
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