Has the owner, applicant or operator ever had a license denied, revoked, or suspended in any state or jurisdiction or been the subject of a disciplinary action or been fined while employed in a child care facility?

 Yes No Have you or anyone identified as a party to ownership ever held a license with any state agency in any capacity other than a driver’s license?
 If yes, where and what type of license? 
 Prior to receiving a license, I, the owner and/or operator and all known child care personnel, have submitted background screening information.

 Falsification of application information is grounds for denial or revocation of the license to operate a child care facility.
 UNDER PENALTY OF PERJURY, I SWEAR AND AFFIRM THAT ALL INFORMATION GIVEN WITHIN THIS APPLICATION IS COMPLETE AND ACCURATE.
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