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Get License Exempt Child Care Center Self Certification Form

State of Illinois Department of Human Services License Exempt Child Care Center Self-Certification Name of Agency/Program/Facility FEIN Address City State Zip Code Phone Number Fax Number E-mail Address Contact Person Please complete the following information as applicable Ages Number of Children Number of Staff Child/Staff Ratio Infants Toddlers Twos 3 s 4 s Kindergarten School Age Indicate the hours of operation Day of the Week Open Close Monda....

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