Form 3015 "Application for a Child Care Administrator License or a Child-Placing Agency Administrator License" - Texas

What Is Form 3015?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3015 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 3015 "Application for a Child Care Administrator License or a Child-Placing Agency Administrator License" - Texas

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Form 3015
October 2020-E
Application for a Child Care Administrator License
or a Child-Placing Agency Administrator License
Use this form to apply for a child care administrator license or a child-placing agency administrator license. This form is not used for day care
director credentialing.
Instructions: Read the instructions carefully and completely before filling out this application.
Questions: Contact the Administrator Licensing Office at 713-696-7119 or ccllicadm@hhsc.state.tx.us.
I. General Information
For Child Care Licensing Use Only
Full Legal Name:
Date Application Is Received:
Other Names That You Have Used (such as a married or maiden name):
First Name:
Middle Name (spell out completely):
Last Name:
Home Mailing Address (including city, county, state, and ZIP code):
Phone Number:
Date of Birth:
Social Security Number:
Email Address (Required):
Driver's License Number/State:
Texas Resident Since (MM/YY):
Job Title:
Operation Name:
Operation Type and Number:
Operation Mailing Address (including city, county, state, and ZIP code):
Operation Phone Number:
II. License Requested
I am applying for a:
Child Care Administrator's License
Child-Placing Agency Administrator's License
III. Education
Institution
Location
Dates Attended
Major
Degree
IV. Professional References
Is (or was) this person
Name
Address
Telephone Number
your supervisor?
Yes
No
Yes
No
Yes
No
V. Fees
Include the following with your mailed application:
$100 nonrefundable application fee
$2 background check fee
Make checks or money orders payable to Texas Health and Human Services Commission
Mail this application and all other required forms to:
Texas Health and Human Services Commission
Administrator Licensing
P.O. Box 16017
RCCL Mail Code 1732
Houston, TX 77222
Form 3015
October 2020-E
Application for a Child Care Administrator License
or a Child-Placing Agency Administrator License
Use this form to apply for a child care administrator license or a child-placing agency administrator license. This form is not used for day care
director credentialing.
Instructions: Read the instructions carefully and completely before filling out this application.
Questions: Contact the Administrator Licensing Office at 713-696-7119 or ccllicadm@hhsc.state.tx.us.
I. General Information
For Child Care Licensing Use Only
Full Legal Name:
Date Application Is Received:
Other Names That You Have Used (such as a married or maiden name):
First Name:
Middle Name (spell out completely):
Last Name:
Home Mailing Address (including city, county, state, and ZIP code):
Phone Number:
Date of Birth:
Social Security Number:
Email Address (Required):
Driver's License Number/State:
Texas Resident Since (MM/YY):
Job Title:
Operation Name:
Operation Type and Number:
Operation Mailing Address (including city, county, state, and ZIP code):
Operation Phone Number:
II. License Requested
I am applying for a:
Child Care Administrator's License
Child-Placing Agency Administrator's License
III. Education
Institution
Location
Dates Attended
Major
Degree
IV. Professional References
Is (or was) this person
Name
Address
Telephone Number
your supervisor?
Yes
No
Yes
No
Yes
No
V. Fees
Include the following with your mailed application:
$100 nonrefundable application fee
$2 background check fee
Make checks or money orders payable to Texas Health and Human Services Commission
Mail this application and all other required forms to:
Texas Health and Human Services Commission
Administrator Licensing
P.O. Box 16017
RCCL Mail Code 1732
Houston, TX 77222
Form 3015
Page 2 / 10-2020-E
VI. Employment History
Instructions: List each position separately, even those held with under the same employer.
Employer (current or most recent):
Mailing Address:
Immediate Supervisor's Name:
Title:
Area Code with Phone No.
Your Job Title:
Are/Were You a Supervisor?
Yes
No
Starting Date (mm/dd/yyyy):
Ending Date (mm/dd/yyyy):
Number of Hours Worked per Week:
Organization's License Type and Number:
Organization's Licensing Agency (such as HHSC, TDCJ, DSHS, etc.):
Adult or Child Clients:
Number of Staff Supervised and Types of Positions:
Describe your duties and responsibilities. Include the following if your position was managerial or supervisory:
• Your responsibilities for implementing the residential child care or child-placing program; and
• Whether your responsibilities included assigning duties, hiring, disciplining, rewarding, approving leave requests and conducting formal
employee evaluations. (Include the number and type of personnel positions that you supervised.)
Form 3015
Page 3 / 10-2020-E
VII. Felony and Professional Charges and Convictions
Check the appropriate box for each question. If you answer “Yes” to any of the following questions, attach an explanatory statement.
1. Have you ever been denied a license or registration to care for children?
Yes
No
2. Have you ever had a license or registration to care for children revoked or suspended?
Yes
No
3. Have you ever been named as the perpetrator of child abuse or neglect after an investigation conducted by the Department
Yes
No
of Family and Protective Services (DFPS) or another state agency in Texas?
4. Have you ever been convicted of a misdemeanor or felony, including convictions in other states?
Yes
No
5. Are you currently charged with a felony or misdemeanor?
Yes
No
6. Have you ever been sustained as a controlling person by HHSC?
Yes
No
VIII. Military Service
Are you currently a military spouse or military service member, or are you a veteran?
No, skip to Section IX.
Yes, complete this section.
Dates of Service (for service members or veterans):
Starting Date:
Ending Date:
Additional Materials Required for the Following:
Military Spouses
Attach documents that demonstrate your status as a military spouse, such as:
• your spouse’s most recent Permanent Change of Station (PCS) order to relocate to Texas; or
• your valid military ID for a military spouse.
Military Service Members
Attach documents that demonstrate your status as a military service member, such as:
• any recent military orders; or
• your valid military ID.
Military Veterans
Attach documents that demonstrate your status as a military veteran, such as your:
• military discharge papers;
• Veterans Affairs ID card; or
• a valid military ID.
IX. Privacy Statement
HHSC values your privacy. For more information, read our privacy policy online at: https://hhs.texas.gov/policies-practices-privacy#security.
X. Certification and Signature
I certify that the information in this application contains no willful misrepresentation or falsification and is true and complete to the best of my
knowledge and belief.
I understand that HHSC may verify any information on this application.
I understand that any willful misrepresentation is cause for immediate denial or subsequent revocation of an administrator's license.
Signature of Applicant
Date Signed
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