Center Name
*
Business Formation Type
*
Please Select
Corporation
LLC
Private Non Profit
Inc.
Limited Partner
Sole Proprietorship
Church Affiliated
Corporation Name
*
Tax ID # or Social Security #
*
Program Type
*
Please Select
Child Care Center
At-Risk Afterschool Program ONLY
Adult Care Center
Homeless Shelter
Profit Status
*
Please Select
For Profit Corp/LLC/Partner
Non-Profit
Center Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Center Address City
*
Street Address
Street Address Line 2
City
State
Zip Code
Center Address State
*
Street Address
Street Address Line 2
City
State
Zip Code
Center Address Zip Code
*
Street Address
Street Address Line 2
City
State
Zip Code
Center's Telephone Number
*
Fax Number
Mobile Telephone Number
*
E-mail
*
example@example.com
Website
Licensing Agency
*
Bright From the Start (CCDivision)
Department of Community Health
Head Start
Licensing Agency
*
Please Select
Bright From the Start (CCDivision)
Department of Community Health
Head Start
Child Care License Number
*
Type Exempt if Exempt from License
Most Recent Fire Inspection Date
*
/
Month
/
Day
Year
Please enter exact date
Contact Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Position
Director
Owner
Assistant Director
Lead Teacher
Cook
Other
County/School District
*
Center Enrollment Number
*
License Capacity
*
How are the meals prepared
Check Days of the week that meals will be served
Center Operating Hours
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Breakfast Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Lunch Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
PM Snack Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Dinner Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Evening Snack Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Nearest Elementary School to the Center
*
(Scan & Upload) NO PHOTOGRAPHS PLEASE Original IRS letter assigning FEIN to entitles legal business name. You can upload the form here or email/fax in the form (770) 938-6869.
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(Scan & Upload)NO PHOTOGRAPHS PLEASE Non-Profit Child Care Center (ONLY for NON-PROFIT CENTERS) 501(C)3 Letter
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(Scan & Upload) NO PHOTOGRAPHS PLEASE Deed or Lease of Center facility with Legal Name
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(Scan & Upload) NO PHOTOGRAPHS PLEASE Child Care License (Bright From the Start)
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