Delaware Health and Social Services
Division of Public Health
 

APPLICATION FOR ADULT DAY CARE LICENSE 

 
FACILITY NAME ______________________________________________________________________
					     Print 
 
FACILITY ADDRESS ___________________________________________________________________
					   ADDRESS 1 

 		 ___________________________________________________________________
					   ADDRESS 2 
 
 		 ______________________________  __________________  _______________
  			     CITY 		       STATE	         ZIP CODE 
 

ADMINISTRATOR  _____________________________________________________________________ 
			 		     Print 

FACILITY CONTACT ___________________________________________________________________
				     Print Name and Title 

PHONE NUMBERS  ____________________________  ___________________________  
 		    AGENCY PHONE NUMBER           AGENCY FAX NUMBER 
  

AGENCY TYPE 			______ PRIVATE		______ NOT FOR PROFIT 
PLEASE CHECK ALL THAT APPLY 
HOURS OF OPERATION:_______ 	______ PUBLIC		______ PROPRIETARY

__________________________ 
  

CAPACITY:_____________  	 OTHER:______________________________________ 
 
 
ACCREDITED? 	______ YES	______ NO 
 
IF YES, NAME OF ACCREDITING ORGANIZATION AND ACCREDITATION EXPIRATION DATE: 
 
____________________________________________________________________________ 
 
Print  
 
PLEASE ATTACH THE MOST CURRENT COPY OF THE FOLLOWING: 
 
1. 	A LIST SHOWING THE NAMES AND ADDRESSES OF EACH OFFICER, DIRECTOR, AND OWNER 
	HAVING FIVE (5) PERCENT OR MORE INTEREST IN THE AGENCY. 

2. 	ACCREDITING AGENCY(IES) REPORT(S) 

3. 	FIRE SAFETY REPORT 

4. OTHER:__________________________________________________________________
 
	 __________________________________________________________________

DOES YOUR AGENCY PROVIDE NURSING SERVICES AS DEFINED IN SECTION 2.0 OF THE 
DELAWARE REGULATIONS FOR ADULT DAY CARE FACILITIES?   
  
 ______ YES 	______ NO 
 
IF YES, NAME AND LICENSE NUMBER OF SUPERVISING NURSE: 
 
_____________________________________________________________________________ 
				  Print 
 
NAME & TITLE OF PERSON DESIGNATED TO ACT IN ABSENCE OF NURSING SUPERVISOR: 
 
_____________________________________________________________________________ 
				  Print 
 
 
 
NAME OF PERSON COMPLETING THIS FORM:______________________________________________ 
 						       Print 
 

SIGNATURE:______________________________________________ 
 
TITLE:______________________________________________ 
 
DATE:_____________________________ 
 

CHECKS SHOULD BE MADE PAYABLE TO:  DELAWARE DIVISION OF PUBLIC HEALTH 
 
INITIAL APPLICATION FEE: $100.00
  
ANNUAL LICENSURE FEE: $50.00
 
 
PLEASE COMPLETE AND RETURN APPLICATION WITH LICENSURE FEE AND ATTACHMENTS TO 
 
OFFICE  OF HEALTH FACILITIES LICENSING & CERTIFICATION 
 
2055 LIMESTONE ROAD 
 
SUITE 200 
 
WILMINGTON DE  19808 
 
Doc No 35-05-20/08/02/47
 
12/05