Form DHR-741 "Information for Licensing Study" - Alabama

What Is Form DHR-741?

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

Form Details:

  • Released on September 1, 2002;
  • The latest edition provided by the Alabama Department of Human Resources;
  • 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 DHR-741 by clicking the link below or browse more documents and templates provided by the Alabama Department of Human Resources.

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ALABAMA DEPARTMENT OF HUMAN RESOURCES
MONTGOMERY, ALABAMA
INFORMATION FOR LICENSING STUDY
Complete and Mail to:
Alabama Department of Human Resources
Office of Resource Management
Gordon Persons Building
50 Ripley Street
Montgomery, Alabama 36130
Type Facility:
Child Care Institution
Child-Placing Agency
Group Home
Facility Name:
_________________________________________________________
Address:
_________________________________________________________
No. and Street
City
County
Zip
Telephone Number:
_________________________________________________________
During Office Hours
After Hours for Emergencies
Applicant Name:
_________________________________________________________
Name of Person or Corporation
____________________________________________________________________________
Name and Title of Person with Responsibility and Authority to Work with Department Representative
Address:
__________________________________________________________________
Telephone Number:
_________________________________________________________
During Office Hours
After Hours for Emergencies
I.
ADMINISTRATION
A. FUNCTION OF THE FACILITY
1. Types of children served
_____________________________________________
___________________________________________________________________
2. Capacity of the Facility
_____________________________________________
3. Ages of children
___________________________________________________
4. Geographic area served
_____________________________________________
___________________________________________________________________
5. Attach a description of the focus and function of the facility, if this is an initial
application or if amended since last application process.
6. Attach any publication giving information in addition to the above.
DHR-741
Revised September 2002
ALABAMA DEPARTMENT OF HUMAN RESOURCES
MONTGOMERY, ALABAMA
INFORMATION FOR LICENSING STUDY
Complete and Mail to:
Alabama Department of Human Resources
Office of Resource Management
Gordon Persons Building
50 Ripley Street
Montgomery, Alabama 36130
Type Facility:
Child Care Institution
Child-Placing Agency
Group Home
Facility Name:
_________________________________________________________
Address:
_________________________________________________________
No. and Street
City
County
Zip
Telephone Number:
_________________________________________________________
During Office Hours
After Hours for Emergencies
Applicant Name:
_________________________________________________________
Name of Person or Corporation
____________________________________________________________________________
Name and Title of Person with Responsibility and Authority to Work with Department Representative
Address:
__________________________________________________________________
Telephone Number:
_________________________________________________________
During Office Hours
After Hours for Emergencies
I.
ADMINISTRATION
A. FUNCTION OF THE FACILITY
1. Types of children served
_____________________________________________
___________________________________________________________________
2. Capacity of the Facility
_____________________________________________
3. Ages of children
___________________________________________________
4. Geographic area served
_____________________________________________
___________________________________________________________________
5. Attach a description of the focus and function of the facility, if this is an initial
application or if amended since last application process.
6. Attach any publication giving information in addition to the above.
DHR-741
Revised September 2002
ALABAMA DEPARTMENT OF HUMAN RESOURCES
MONTGOMERY, ALABAMA
INFORMATION FOR LICENSING STUDY
B. ADMISSION AND DISCHARGE
Attach copies of admission and discharge policies and practices, if this is an initial
application or if amended since last application process.
C. BOARD
1. If there is a board, describe how members are appointed.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
2. How often does the board meet? _________________________________________
3. Dates of regular meetings ______________________________________________
___________________________________________________________________
4. Attach a list of the names and addresses of all members of the Board; indicate when
the term of each expires; specify the Chairman and committee members of each
committee of the Board.
D. ORGANIZATION
1. If incorporated, attach copy of incorporation papers, if this is an initial application or if
amended since last application process.
2. Attach copy of by-laws and constitution, if this is an initial application or it amended
since last application process.
E. FINANCIAL INFORMATION
1. Attach copy of projected or current budget.
2. Attach copy of most current audit, if applicable.
3. Attach policies regarding charges and services, if this is an initial application or if
amended since last application process.
F. PERSONNEL
1. Attach copy of personnel policies, including job description and qualifications, if this
is an initial application or if amended since last application process.
2. List staff members and give requested information. (Attach additional sheets as
necessary to indicate duties assigned other than indicated by the title of the position.
DHR-741
Revised September 2002
ALABAMA DEPARTMENT OF HUMAN RESOURCES
MONTGOMERY, ALABAMA
INFORMATION FOR LICENSING STUDY
Name
Position
Age
Education (No. of Years)
# Years
# Hrs of
Experience
Degrees
Work
in Field of
High
Under-
Graduate
Per Wk
Child Care
School
graduate
DHR-741
Revised September 2002
ALABAMA DEPARTMENT OF HUMAN RESOURCES
MONTGOMERY, ALABAMA
INFORMATION FOR LICENSING STUDY
II. SOCIAL SERVICE
Attach a detailed and specific description of the provision for social services, if applicable.
(If social service is provided through another source, attach a copy of the written agreement
or contract along with the above.)
III. PLANT (Not applicable for Child-Placing Agencies)
A. Attach a certificate of approval based on an inspection by the fire department, made
within the last three months.
B. Attach a certificate of approval based on an inspection by the health department, made
within the last three months.
C. Attach a statement showing compliance with all local zoning laws, where applicable.
I / We certify that the information given on this form is true and correct to the best of my / our
knowledge. I / We understand that any misrepresentation of information may be grounds for
denial of the application.
Signature:
_______________________________________________
(Executive)
Signature:
_______________________________________________
(Board Chairman)
Date: ___________________
DHR-741
Revised September 2002
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