Form 032-05-0703-03-ENG "Renewal Application for Licensure of a Child Welfare Agency, Assisted Living Facility, or Adult Day Care Center" - Virginia

Form 032-05-0703-03-ENG Printable Pdf
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What Is Form 032-05-0703-03-ENG?

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

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Virginia Department of Social 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 printable version of Form 032-05-0703-03-ENG by clicking the link below or browse more documents and templates provided by the Virginia Department of Social Services.

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Download Form 032-05-0703-03-ENG "Renewal Application for Licensure of a Child Welfare Agency, Assisted Living Facility, or Adult Day Care Center" - Virginia

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VIRGINIA DEPARTMENT OF SOCIAL SERVICES
DIVISION OF LICENSING PROGRAMS
RENEWAL APPLICATION FOR LICENSURE OF A CHILD WELFARE AGENCY,
ASSISTED LIVING FACILITY, OR ADULT DAY CARE CENTER
Instructions: To ensure timely processing, the applicant must submit a complete renewal application to the area
Licensing Office at least 60 days prior to the expiration date of the current license. A complete renewal
application includes: 1) Part I: Applicant Information and required attachments, 2) Part II: Program Addendum
to the Application and required attachments, and 3) the renewal fee.
incomplete renewal application will delay the review process.
Submission of an
If the Licensing Office
finds the application incomplete, the applicant will be notified in writing within 15 days of receipt of the
incomplete application. If the applicant does not submit a complete renewal application including all required
attachments prior to the expiration date of the current license, the license will expire. It is illegal to operate a
facility subject to licensure without obtaining a license.
Review carefully; not all sections apply. Please type or print legibly using permanent, black ink and retain a copy
for your records. Please contact the licensing office in your area if there are any questions relating to the
completion of this application.
NOTE: Renewal of this license is contingent upon the payment of any outstanding fees or outstanding fines
previously imposed as a sanction against this license that were not appealed or that were affirmed at an
administrative hearing. If at the time of this license renewal application, there is a pending administrative
hearing resulting from a proposed fine, it will not affect the renewal of this license.
PART I : APPLICANT INFORMATION (
ALL APPLICANTS MUST COMPLETE)
SECTION 1 – GENERAL INFORMATION
FACILITY TYPE: (Select only one per application.)
Adult Day Care Center
Assisted Living Facility
Child-Placing Agency
Children’s Residential Facility
Child Day Center
Child Caring Institution
Family Day System
Independent Foster Home
Family Day Home
____________________________
Name of Family Day Home Licensee
FACILITY INFORMATION (To be completed by all applicants.)
Name of the Facility:__________________________________________________________________
Telephone Number: (
)_________________________ Fax Number: (
)___________________________
_____________________________________________________________________________________________
Facility Street Address (physical address)
City
State
Zip Code
_____________________________________________________________________________________________
Facility Mailing Address (
Same as physical address)
City
State
Zip Code
For Department Use Only
DATE: __________ REC’D BY: __________ INSPECTOR: ___________
CHECK/MO #: ____________________ AMT REC’D _________ FACILITY #: _______________
AMOUNT OF OUTSTANDING FEES AND FINES: _____________________
032-05-0703-03-eng (1/14)
Page 1 of 17
VIRGINIA DEPARTMENT OF SOCIAL SERVICES
DIVISION OF LICENSING PROGRAMS
RENEWAL APPLICATION FOR LICENSURE OF A CHILD WELFARE AGENCY,
ASSISTED LIVING FACILITY, OR ADULT DAY CARE CENTER
Instructions: To ensure timely processing, the applicant must submit a complete renewal application to the area
Licensing Office at least 60 days prior to the expiration date of the current license. A complete renewal
application includes: 1) Part I: Applicant Information and required attachments, 2) Part II: Program Addendum
to the Application and required attachments, and 3) the renewal fee.
incomplete renewal application will delay the review process.
Submission of an
If the Licensing Office
finds the application incomplete, the applicant will be notified in writing within 15 days of receipt of the
incomplete application. If the applicant does not submit a complete renewal application including all required
attachments prior to the expiration date of the current license, the license will expire. It is illegal to operate a
facility subject to licensure without obtaining a license.
Review carefully; not all sections apply. Please type or print legibly using permanent, black ink and retain a copy
for your records. Please contact the licensing office in your area if there are any questions relating to the
completion of this application.
NOTE: Renewal of this license is contingent upon the payment of any outstanding fees or outstanding fines
previously imposed as a sanction against this license that were not appealed or that were affirmed at an
administrative hearing. If at the time of this license renewal application, there is a pending administrative
hearing resulting from a proposed fine, it will not affect the renewal of this license.
PART I : APPLICANT INFORMATION (
ALL APPLICANTS MUST COMPLETE)
SECTION 1 – GENERAL INFORMATION
FACILITY TYPE: (Select only one per application.)
Adult Day Care Center
Assisted Living Facility
Child-Placing Agency
Children’s Residential Facility
Child Day Center
Child Caring Institution
Family Day System
Independent Foster Home
Family Day Home
____________________________
Name of Family Day Home Licensee
FACILITY INFORMATION (To be completed by all applicants.)
Name of the Facility:__________________________________________________________________
Telephone Number: (
)_________________________ Fax Number: (
)___________________________
_____________________________________________________________________________________________
Facility Street Address (physical address)
City
State
Zip Code
_____________________________________________________________________________________________
Facility Mailing Address (
Same as physical address)
City
State
Zip Code
For Department Use Only
DATE: __________ REC’D BY: __________ INSPECTOR: ___________
CHECK/MO #: ____________________ AMT REC’D _________ FACILITY #: _______________
AMOUNT OF OUTSTANDING FEES AND FINES: _____________________
032-05-0703-03-eng (1/14)
Page 1 of 17
County or City in which facility is located:___________________________________________________________
E-Mail Address (one email address per facility): ___________________________________
Do not have Email
Directions to Facility:_____________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 2 – TYPE OF BUSINESS ENTITY
BUSINESS TYPE APPLYING FOR LICENSE:
(Check only one type)
An Individual (Sole Proprietorship)
Complete Subsection A
A Partnership
Complete Subsection B
A Corporation
Complete Subsection C
An Association
Complete Subsection D
A Limited Liability Company
Complete Subsection E
A Public Agency
Complete Subsection F
A Business Trust
Complete Subsection G
A Religious Organization (if not a
Complete Subsection H
business type listed above)
032-05-0703-03-eng (1/14)
Page 2 of 17
SUBSECTION A – INDIVIDUAL / SOLE PROPRIETORSHIP (One person is applying)
Name (First, Middle or Maiden, Last):______________________________________________________
Mailing Address:_______________________________________________________________________
Street/P.O. Box
City
State
Zip Code
_______________________________
or
_______________________________________
Social Security Number
Federal Employer Identification Number (FEIN)
032-05-0703-03-eng (1/14)
Page 3 of 17
SUBSECTION B – PARTNERSHIP
General Partnership
Limited Partnership
1. Identifying Information:
Name of Partnership Applying for License: _______________________________________________________
Partnership Mailing Address: _____________________________________________________________
Street/P.O. Box
City
State
Zip Code
Partnership Tax ID Number:__________________________
Phone Number: (____)________________
Designated Contact Person:
Title:______________________________
_______________________________________
Provide the following information on each general and limited partner: (A
ttach additional pages if needed.)
Name
Title
Address_______________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
List the name, title and address of any agent(s) other than the partners who is empowered to act on behalf of
the partnership in matters relating to the facility:_______________________________________________
______________________________________________________________________________________
032-05-0703-03-eng (1/14)
Page 4 of 17
2. Names of individual, association, limited liability company, corporation, etc., with 5% or more
ownership interest in the partnership applying for the license:
Name
Ownership Percentage
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
NOTE: These individuals are not required to submit background checks, references, or Personal
Qualifying Information unless they are also listed in #1 above (Identifying Information).
032-05-0703-03-eng (1/14)
Page 5 of 17
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