Follow the steps to successfully complete your certification form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Enter the name of your agency, program, or facility in the designated field at the top of the form.
3. Fill in your Federal Employer Identification Number (FEIN) accurately in the specified section.
4. Provide the complete address, including the city, state, and zip code of your facility.
5. Include a valid phone number for your center to ensure easy communication.
6. If applicable, provide your facility’s fax number.
7. Enter the email address for the contact person, ensuring it is accurate for correspondence.
8. List the contact person’s name who will be responsible for inquiries regarding the program.
9. Specify the ages of children in your care by filling in the number of children you serve for each age group provided.
10. Indicate the total number of staff members working in your facility.
11. Fill in the child-to-staff ratio to confirm compliance with safety regulations.
12. For each day of the week, indicate the hours your center operates by entering the opening and closing times.
13. Review the exemption criteria listed and select those that apply to your program.
14. Answer the compliance questions regarding local health clearances and safety ordinances by selecting 'Yes' or 'No.'
15. Indicate whether you would like your center's information included in the local Resource & Referral database.
16. Sign and date the form in the designated fields, printing your name clearly.
17. Attach any required documents, including health and safety standard checklists, CANTS forms, and health reports.
18. Once all sections are completed, save changes, then download, print, or share the form as needed.

Begin filling out your License Exempt Child Care Center Self Certification Form online today!