Application for License to Operate a Chemical Dependency Treatment 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

Administrator

Physical Address

Mailing Address


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

Capacity and Classification of Facility

Number of Licensed Beds:

Accreditation


Inpatient Chemical Dependency Treatment Facility Accreditation under SDCL 34-20A:	Full Accreditation	Conditional
Period of Accreditation

Period of Accreditation