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Further licence application - individual non school provider form

By Amber Fox,2014-04-16 21:22
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Further licence application - individual non school provider form

     CSFL 01

    Children’s service licence application

    by an individual

    Further licence for current provider

    (Not service provided by school)

     Office Use Only NOTE 1: The information you are asked to provide on this Provider application number form is being obtained for the purposes of the licensing of Provider licence number children’s services in NSW. The information will be used by DoCS for this purpose. All personal details provided will be File Reference number kept confidential to DoCS other than those details which must be displayed on a licence.

    1. Licence details

     Licence number Licence expiry date / /

2. Licensee’s details

    Title e.g. Mr/Ms Surname Given name Middle name Former name

    Date of birth / / Gender Male Female

     Town/city of birth Country of birth Postal address

    Suburb/town Postcode Residential address (if

    different from Suburb/town Postcode postal address)

    Home phone ( ) Daytime phone ( ) Mobile Fax

    Email

    3. Person for DoCS to contact about this application (if different from licensee’s details above) Title e.g. Mr/Ms Surname Given name Middle name Former name

    Daytime phone ( ) Fax ( ) Mobile Email

    4. Service details (service type and street address must be same as current licence details) Type of service Centre based Mobile service Family day care Home based

    Name of service

    Street address (for mobile services and family day

    care give address