Instructions for Completing the Initial Licensure Application

These instructions are provided to assist you in completing an initial application for licensure.

Before beginning, please make certain that the application (PDF, 283 KB) you are using is the most recent and appropriate application. The section does not provide funding or placement of clients.

Failure to provide all requested information will result in delaying the processing of the application. If the information requested does not pertain to your facility, mark N/A in the area.

Facility Information:

Beginning of Initial Licensure Application For MH/DD/SAS Facilities (PDF, 283 KB)

  1. Facility Name: Enter name of your facility. This is the name that will be printed on your license.
  2. Facility Site Address: This address is the physical location of your facility.
  3. Facility Correspondence Mailing Address: This address will be where you will receive all mail pertaining to the facility. It may be the same as the facility site address, or it may be the address of your management agency, corporation, individual, owner, etc. Indicate the name to address correspondence.
  4. Name of Facility Director: This will be the person who is responsible for managing the facility.
  5. Name of Contact Person: This may be you or the person responsible for managing the facility. This person can answer daily process and licensure questions about the facility.
  6. Signature of Licensee or Person with Signatory Authority: Sign and date.
  7. Management Company: Enter this information if the facility will be managed by a company other than the licensee.
  8. Local Management Entity (LME): Enter the names of LMEs with which the facility has a contract.
  9. Legal Identity of Ownership/Licensee: This is the name that will be printed on the license as licensee/owner.
    1. Enter name and contact information of owner of the business.
    2. Federal Tax ID# - if applicable.
    3. Check if you are registered with the state as profit or non-profit.
    4. Type of entity under which the business is operated. All entities should be registered with the state except proprietorship and private partnership.
    5. Supply information for CEO or President.
    6. If you lease the building, complete the data on the person from whom you lease/rent.
  10. Owners, Partners, Affiliates, Shareholders (Confidential Information for Official Use Only):
    • If this is a proprietorship (private) business with no shareholders or a non- profit entity, signature and title and date needed in 1st box.
    • If the ownership has investors or shareholders in the business, fill in the information requested. If ownership is a corporation/company having only 1 person who is sole owner, please fill in as percentage interest is 100%. Social Security numbers are requested, but voluntary.
  11. Extensions in Ownership: Enter information about affiliates who directly or indirectly control the owner of this facility.
  12. Service Categories: Check the category that describes the service/s your facility will provide. For residential facilities, enter the number of beds under either the children category or adult category.
  13. Certificate of Need: Used only upon licensing for service categories .2100, .3400 or .5600 state sanctioned ICF/IID facility.
  14. Number of Clients: Note the number of clients you will serve and the disability category or categories that you will serve.
  15. Number of Others Living in the Facility: Completed by those requesting to be licensed as service category .5600F & .5100-Private Home Respite only. Include the number and ages of anyone that lives in the facility that is not a client.