Child Care Licensing Controlling Person Disclosure Form

Child Care Licensing Controlling Person Disclosure Form
Please provide information to disclose all controlling persons associated with the child care licensing applicant or facility. Complete all fields accurately. Do not provide any sensitive identification or financial information.
Applicant or Facility Name
Controlling Person's Full Name
First NameLast Name
Role or Relationship to Applicant/Facility
Controlling Person's Email Address
example@example.com
Controlling Person's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Controlling Person's Home or Business Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Control or Interest
Other
Percentage of Ownership or Control
Has this controlling person ever been involved in regulatory actions or license revocations related to child care or similar services?
Has this controlling person ever been convicted of a felony or crime related to child care or similar services?
Should be Empty: