Application for a License to Operate an Assisted Living Center

Name and Location of Facility

Name and Location of Facility

Legal Business Name: Must be exactly as name appears on legal documents.


Do you have a DBA (Doing Business As)?	Yes	No


DBA Name: Must be exactly as name appears on legal documents.
Contact Information

Contact Information


Telephone Number:	Extension:	Fax Number:
Administrator

Administrator


First Name:	Last Name:	Title:	Email Address:
Upload proof of administrator qualifications and attestation that statement 44:70 has been read. Drop file(s) here or Maximum files: 10. Uploaded File(s) Click here for recommendations on uploading files.

Physical Address

Physical Address


Address of Facility:
Address Line 2:
City:	County:	State:	ZIP Code:

Mailing Address

Mailing Address


Is your mailing address different from the address above?	Yes	No


Mailing Address:
Address Line 2:
City:	State:	ZIP Code:

Capacity and Classification of Facility