INITIAL APPLICATION FOR LICENSE TO OPERATE A HOME 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION I, where you select the type of application. Choose between 'New Facility' or 'Change of Ownership' and provide the anticipated date if applicable.
3. In SECTION II, fill out your identifying information. Include the practice location, agency name, address, and contact details. Ensure that all fields are completed legibly.
4. Proceed to SECTION III for staffing details. Enter names and qualifications for key personnel such as the Administrator and Clinical Supervisor. Attach required documentation like resumes and licenses.
5. In SECTION IV, disclose ownership information by listing individuals with a controlling interest in the agency. Be thorough to avoid delays.
6. Complete SECTION VII by certifying your application with an authorized signature, ensuring all statements are accurate and complete.
7. Finally, review SECTION VIII for documentation requirements and ensure all necessary attachments are included before submission.

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