Get Flis Licapp 001 Affidavit 2009-2025

The Flis Licapp 001 Affidavit is a crucial document for individuals or entities looking to apply for a license with the Connecticut Department of Public Health. This guide provides a clear, step-by-step instruction on how to accurately complete the affidavit online.

Follow the steps to fill out the Flis Licapp 001 Affidavit online.

1. Press the ‘Get Form’ button to access the Flis Licapp 001 Affidavit and open it in your online editor.
2. Begin by selecting the appropriate application type: initial or renewal. Ensure that you check the box corresponding to your application status.
3. Complete the facility 'doing business as' name and business address fields accurately, including city, state, and zip code.
4. Provide the contact telephone number for the business along with the mailing address if it differs from the business address.
5. Indicate the bed capacity requested by listing levels of care. Specify the number of beds and any hemodialysis stations or bassinets as applicable.
6. Insert the Federal Employer Identification Number in the provided space.
7. Disclose the legal entity that owns or operates the facility. Include the business address and contact information for this entity.
8. Select the legal entity type by checking the appropriate box. Options include individual, trust, corporation, and others.
9. Answer whether the named entity is authorized to transact business in Connecticut by selecting 'Yes' or 'No.'
10. Provide contact details for the Agent for Service representing the Licensee, including name, address, and telephone.
11. Attach an organizational chart that outlines the ownership structure of the licensee.
12. Compile and attach various required documents including insurance certificates and guarantees.
13. Complete the affidavit portion by providing truthful attestations and signing it in the designated area. Don’t forget to have it notarized.
14. Once all fields are filled out and documents attached, save your changes, and then choose to download, print, or share the completed affidavit.

Start your application process by filling out the Flis Licapp 001 Affidavit online today.