Get Flis Licapp 001 Form

The Flis Licapp 001 form is a critical document for applying for a facility license in Connecticut. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring users have the necessary information to fill out each section accurately.

Follow the steps to successfully complete the Flis Licapp 001 form online.

1. Click the ‘Get Form’ button to obtain the form and open it for editing.
2. Select whether you are submitting an initial application or a renewal application by checking the appropriate box at the top of the form.
3. Indicate the type of facility you are applying for by checking the relevant boxes; ensure that you list all applicable levels of care.
4. Fill in the facility 'doing business as' (d/b/a) name, business address, and contact information in the specified fields.
5. Complete the bed capacity requested for each level of care if applicable, including bassinets and hemodialysis stations.
6. Provide the Federal Employer Identification Number in the designated field.
7. Enter the legal entity that owns and operates the facility, along with its address and contact details.
8. Check the appropriate box corresponding to the type of legal entity that owns the facility.
9. Indicate whether the entity is in good standing with the Office of the Secretary of State.
10. Complete the information of the Agent for Service for the Licensee.
11. Attach necessary documents such as an organizational chart, insurance certificates, and compliance evidence as outlined by the form.
12. Review all completed sections for accuracy to avoid any application delays.
13. Once satisfied with the application, save changes, then proceed to download, print, or share the form as needed.

Complete your Flis Licapp 001 form online to ensure a smooth application process.