Follow the steps to complete your application seamlessly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the name of your facility at the top of the form. Ensure that this is the official name as registered with the licensing office.
3. Fill in the facility address, including the number, street, city, state, and ZIP code, ensuring accuracy to facilitate communication and compliance.
4. Input the name of the administrator of the facility, along with their contact telephone number. This information is crucial in emergency situations.
5. Detail the assignments during an emergency by listing the title, assignment, and names of staff responsible for each task. Utilize the reverse side of the form if additional space is needed.
6. List emergency names and telephone numbers for key services, such as police, fire department, and hospital. This information is vital for immediate access during emergencies.
7. Indicate facility exit locations by referring to the facility sketch (LIC 999), ensuring all exits are clearly marked for safety.
8. If applicable, state the temporary relocation site(s) along with the name, address, and telephone number of the site. Ensure you have permission from the relevant party to submit this information.
9. Specify utility shut-off locations, marking them on the facility sketch (LIC 999). Include electricity, water, and gas shut-off points.
10. Indicate the location of the first aid kit, smoke detectors, fire extinguishers, and any other safety equipment required for emergencies.
11. Complete the affirmation statement by signing your name and entering the date. This confirms your responsibility for the emergency services plan.
12. Once all sections are filled out, review the completed form for accuracy. Users can then save changes, download a copy, print, or share the form as needed.

Complete your form online now to ensure your facility is prepared for emergencies.