State Licensing Inspection Request State License Type (required) Adult Day Program Childcare Home Care Agency Other License Status (required)New License Renew Existing License Modify Existing License Business/Facility Information Business/Facility Name (DBA) (required) Business Phone (required) Address to Be Inspected (required) Unit (required) City (required) County (required) Monitored Fire Alarm Installed? (required) Yes No Automatic Fire Sprinklers Installed? (required) Yes No How many care recipients are you requesting to have? (required) Care Recipient Age Range (required)Under 2 1/2 Years 2 1/2 Years to 18 years old Over 18 Years Old Contact Information Business Owner or Director’s Name (required) Business Owner or Director’s Phone (required) Business Owner or Director’s Email (required) State Licensing Agent Name (required) State Licensing Agent Phone (required) State Licensing Agent Email (required) There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received. Do not use this site to submit Medical Transport Payments
