Delaware Health and Social Services
Division of Public Health 
 
APPLICATION FOR PERSONAL ASSISTANCE SERVICES AGENCY LICENSE 

AGENCY NAME ________________________________________________________________________
					     Print 
 
AGENCY ADDRESS _____________________________________________________________________
					   ADDRESS 1 

 		 ___________________________________________________________________
					   ADDRESS 2 
 
 		 ______________________________  __________________  _______________
  			     CITY 		       STATE	         ZIP CODE 
 

DIRECTOR ___________________________________________________________________________ 
			 		     Print 
 
OTHER CONTACT ______________________________________________________________________
AS APPROPRIATE  			      Print 

PHONE NUMBERS  ______________________  ______________________  _____________________ 
  	        AGENCY PHONE NUMBER      AGENCY PHONE NUMBER      EMAIL ADDRESS   
 
  
AGENCY TYPE 			______ PRIVATE		______ NOT FOR PROFIT 
PLEASE CHECK ALL THAT APPLY
				______ PUBLIC		______ PROPRIETARY 
 
oFFICE HOURS:____________	______ EMPLOYEES ONLY	______ CONTRACTORS ONLY
 
_________________________  	______ EMPLOYEES AND CONTRACTORS 
 
 
GEOGRAPHIC AREA SERVED:  ___________________________________________________________ 
  				                  Print 
  

SERVICES PROVIDED: 	_____ ADLS		_____ LIVE IN 

			_____ COMPANIONSHIP	_____ HOMEMAKER 
  
  			_____ TRANSPORTATION	_____ LICENSED HOME HEALTH 
  						
			_____ OTHER (PLEASE LIST) 
  
 			___________________  ___________________  __________________
  
  
INITIAL APPLICATION FEE: $250.00
  
ANNUAL LICENSURE FEE: $100.00 


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. 	A LIST SHOWING THE NAMES AND ADDRESSES OF THE GOVERNING BODY, IF DIFFERENT 
	FROM THE PRECEDING GROUP. 

3. 	HOME HEALTH AGENCY LICENSE (IF DUALLY LICENSED) 

4. 	OTHER: ___________________________________________________________________
 
 
NAME OF PERSON COMPLETING THIS FORM:______________________________________________ 
                                                        Print 
 
                          SIGNATURE:______________________________________________ 
 
                              TITLE:______________________________________________ 
 
                                                DATE:_____________________________ 
 
 
CHECKS SHOULD BE MADE PAYABLE TO:  DELAWARE DIVISION OF PUBLIC HEALTH 
 
ANNUAL LICENSURE FEE: 
 
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 
 
05/07  

Doc. No. # 35-05-20/08/02/56