Has the owner, applicant or director 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 If yes, please explain (attach additional sheet(s) if necessary):
 
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?

 Prior to receiving a license, I , the owner and/or director and all known child care personnel, have submitted background screening information. Yes No If no, please explain (attach additional sheet(s) if necessary):

 Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), personally identifiable health information must be protected from disclosure and maintained in a manner to prevent inadvertent disclosure to the public and to otherwise assure the privacy of such information. Your signature on this application indicates that you agree to comply with the requirements of HIPAA by protecting the confidentiality of employee and children's health records in your possession. 
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