Childcare Center License Renewal Request Form
Center Information
Center Name
License Number
Address
City
State
ZIP Code
Phone Number
Email Address
Director/Owner Information
Director/Owner Name
Director/Owner Phone
Director/Owner Email
Renewal Details
Current License Expiration Date
Date of Last Inspection
Maximum Child Capacity
Type of Renewal
Regular
Provisional
Any Changes Since Last Renewal?
Yes
No
If Yes, Please Describe Changes
Certification
Name of Person Submitting Form
Date
Signature