Free 53844.FH11 - Indiana

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APPLICATION FOR REGISTERED UNLICENSED CHILD CARE MINISTRIES
State Form 53844 (R / 3-09) Approved by State Board of Accounts, 2009

INDIANA DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE AND BUILDING SAFETY 302 West Washington Street, Room E241 Indianapolis, IN 46204 Telephone: (317) 232-2222

INSTRUCTIONS:

1. 2. 3. 4.

Complete this form. Prepare a letter listing all of the rooms and areas of the building which are used by the child care ministry. Please mail the form, the $50.00 application fee, and the letter to the above address. Please make check payable to the Indiana Department of Homeland Security.

NOTE:

This application must be signed by the president, chairman of the board, or other governing body for the religious organization operating this registered unlicensed child care ministry. Failure to file a legible, properly completed application may result in the application being rejected.

REGISTERED UNLICENSED CHILD CARE MINISTRY INFORMATION
Name of registered unlicensed child care ministry

Address (number and street, city, state, and ZIP code)

County

Telephone number

Alternate telephone number

(
Name of director

)

(

)

E-mail address of director / facility

APPLICANT INFORMATION
Name of applicant (religious organization responsible for operating the child care ministry)

Address (number and street, city, state, and ZIP code)

County

Telephone number of applicant

(

)

I hereby certify that all information given herein is true and complete to the best of my knowledge, and that any false statement will be cause for voiding this application.
Signature Date (month, day, year)

Title

FOR OFFICE USE ONLY
RM number Fee identification Date received (month, day, year) Block

Registered

Re-registered

A

B