Form OCC672 "Request for Continuing License or Letter of Compliance" - Maryland

What Is Form OCC672?

This is a legal form that was released by the Maryland State Department of Education - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2015;
  • The latest edition provided by the Maryland State Department of Education;
  • 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 printable version of Form OCC672 by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

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Download Form OCC672 "Request for Continuing License or Letter of Compliance" - Maryland

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MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
REQUEST FOR CONTINUING LICENSE OR LETTER OF COMPLIANCE
FACILITY:
___________________
LICENSE/LOC #: __________________
The above named facility's license or letter of compliance is due to expire on
____
.
Please check your preference below and mail back to:
Licensing Specialist _______________________________________ Phone __________________________
Address: _________________________________________________________________________________
Email: ___________________________________________________________________________________
I will not continue to provide child care beyond the expiration date of my license or LOC. I will
voluntarily close my child care facility by the above noted expiration date.
Signature ____________________________________________________ Date _______________________
I desire to continue to provide child care beyond the expiration date of my license or Letter of
Compliance and hereby submit the required documentation for conversion of my current license/LOC to
continuing (non-expiring) status. I agree to abide by the requirements of COMAR 13A.16.01-.19 or
COMAR 13A.17.01-.17, as applicable. I understand that reporting false information may be grounds for
denial or revocation of my license or Letter of Compliance.
Signature ____________________________________________________ Date _______________________
List all residents on the premises on page 2 of this form, and complete the section related to Workers'
Compensation Insurance, if applicable.
OCC 672 - Revised 3/15 - All previous editions are obsolete.
Page 1 of 2
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
REQUEST FOR CONTINUING LICENSE OR LETTER OF COMPLIANCE
FACILITY:
___________________
LICENSE/LOC #: __________________
The above named facility's license or letter of compliance is due to expire on
____
.
Please check your preference below and mail back to:
Licensing Specialist _______________________________________ Phone __________________________
Address: _________________________________________________________________________________
Email: ___________________________________________________________________________________
I will not continue to provide child care beyond the expiration date of my license or LOC. I will
voluntarily close my child care facility by the above noted expiration date.
Signature ____________________________________________________ Date _______________________
I desire to continue to provide child care beyond the expiration date of my license or Letter of
Compliance and hereby submit the required documentation for conversion of my current license/LOC to
continuing (non-expiring) status. I agree to abide by the requirements of COMAR 13A.16.01-.19 or
COMAR 13A.17.01-.17, as applicable. I understand that reporting false information may be grounds for
denial or revocation of my license or Letter of Compliance.
Signature ____________________________________________________ Date _______________________
List all residents on the premises on page 2 of this form, and complete the section related to Workers'
Compensation Insurance, if applicable.
OCC 672 - Revised 3/15 - All previous editions are obsolete.
Page 1 of 2
Request for Continuing License/LOC (continued)
WORKERS' COMPENSATION INSURANCE INFORMATION
Pursuant to the Maryland Workers' Compensation Act (Title 9 of the Labor and Employment Article, Annotated Code of Maryland),
the applicant must have worker’s compensation insurance coverage if the facility has one or more employees. Please provide the
following information about that coverage:
Name of Insurance Company: _________________________________________________________________________________
Insurance Policy/Binder Number: ______________________________________________________________________________
Effective Date of Coverage: ______________________________
Expiration Date: ____________________________________
RESIDENTS ON THE PREMISES
Does any person reside on the premises of the facility?
YES
NO
If "YES," please provide the following information for each person living on the premises.
FULL NAME
BIRTHDATE
RELATIONSHIP
RACE
MARITAL
SOCIAL SECURITY #
STATUS
OCC 672 - Revised 3/15 - All previous editions obsolete.
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