Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Indicate whether this application is for an initial license or to renew an existing license. Select the appropriate option by filling in the corresponding box.
3. Provide the name, address, telephone number, and email of the person completing the application. Specify their role in the facility's operation, such as licensee or manager.
4. In Section I: General Information, enter the applicant's name, physical address of the facility, and any different mailing address, along with the facility's contact number.
5. Specify the requested capacity and age range of residents the facility intends to serve. Mark the appropriate checkboxes indicating the sexes of residents and any specific conditions that the facility can accommodate.
6. Outline the levels of support the facility is prepared to provide and provide any additional details about residents that the facility cannot accommodate.
7. In Section III, present ownership and management details, including names and social security numbers of owners or board members if applicable.
8. Compile and attach additional documentation as required in Section IV. This includes facility inspection certificates, employee training data, promotional materials, and compliance documentation.
9. Complete Section V: Affidavit, providing any required disclosures on previous licenses or allegations if applicable. Ensure to initialize each statement that applies to your application.
10. Once all sections are completed, review the entire form for accuracy. You can then save changes, download, or print your completed application as needed.

Begin your application process online today to ensure your facility is licensed without delay.