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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 Suburb/town Postcode of service office)

    Email Phone no. ( ) Fax no. ( ) CSFL 01 Further licence application Individual non school provider Page 1 of 3 17/09/2009

5. Nominated authorised supervisor (AS)

NOTE 1: This section is not applicable to home-based services

    NOTE 2: Complete this section if you are replacing current AS or appointing second AS (service can have one or two

    authorised supervisors)

    NOTE 3: For each AS complete and attach AS nomination form CSAS 01

    Surname Given name Middle name Former name Title

    AS 1

    Date of birth / / Gender Male Female

    Surname Given name Middle name Former name Title

    AS 2

    Date of birth / / Gender Male Female

    6. Maximum number of children For mobile service attach CSVI 01 Venue Information for Mobile Children’s

    Service for each venue

    Tick box if same as If different from current Proposed current licensed licensed number insert numbers number current number Maximum total number

     Max. number between 0 < 2 years

     Max. number between 2 < 3 years

     Max. number between 3 < 6 years * NOTE: If the maximum total number is to be greater than the current maximum licensed total number or the service is

    starting to take on 0<2year olds you must attach a completed form CSDF04 Statement of premises compliance.

    7. Days, hours and weeks of operation For mobile service attach CSVI 01 Venue information for mobile children’s service for each venue

    Current information on licence

    Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Opening time Closing time Number of weeks per year

    New information (if different from current information on licence)

    Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Opening time Closing time Number of weeks per year

    8. Documents to attach to this form

    Document Notes Do Document attached?

    Not required if current 1. Statement that to best of applicant’s knowledge documents 2 to 4 attached there have been no structural alterations to Yes No premises other than (if applicable) DoCS

    approved alterations

    Not required if document 1 2. Two copies of current site & building plans attached drawn by architect/person accredited by Building N/A Yes No Designers Association of NSW Inc in relation to

    class of buildings concerned

    Not required if document 1 3. CSDF 04 Statement of premises compliance OR attached CSDF 05 Statement of premises non-

    compliance signed by architect/person N/A Yes No accredited by Building Designers Association of

    NSW Inc in relation to class of buildings

    concerned

    CSFL 01 Further licence application Individual non school provider Page 2 of 3 17/09/2009

    Not required if document 1 4. Copy of occupation certificate under attached N/A Environmental Planning and Assessment Act Yes No 1979 for use of premises for service

    For applicant if he/she has 5. CSPI 01 - Personal information form not submitted one in the last 3 years OR if he/she has submitted one in the last 3 N/A Yes No years but some of the information is no longer current

    See section 5 of this form.- 6. CSAS 01 - Authorised supervisor nomination one per AS. Not applicable N/A Yes No form/s for home based services

    Mobile services only one 7. CSVI 01 Venue information for mobile children’s per venue. Only required if N/A Yes No service (if applicable) adding new venue

    Mobile services only. Only 8. CSDF 06 Statement of venue non-compliance required if adding new and venue management plan (if applicable) venue which is non-N/A Yes No complying

    Home based services only. 9. Certified copy of applicant’s current approved first Refer to DoCS website for N/A Yes No aid qualification approved qualifications

9. Undertaking and declaration by applicant

     , I,

    Full name of applicant

    undertake that at all times during the term of the licence I will conduct such checks as are necessary to ensure: a) that the premises of the children’s service which is the subject of this application comply with the facilities

    and equipment requirements in Part 3 of the Children’s Services Regulation 2004 applicable to the service

    the subject of the application or, where this is an application for a licence for a mobile children’s service

    accompanied by a venue management plan, that the premises comply with the venue management plan

    and

    b) the service is conducted in accordance with the operational requirements and administrative

    requirements in Parts 6 and 7 respectively of the Regulation applicable to the service

     and

    c) all individuals involved or proposed to be involved in the operation or management of the service

    (including any person engaged as a volunteer) have been checked as required by the Regulation.

    and I declare that:

    d) I will be the provider of the service, the subject of this application

    e) the information in this application, including in all documents attached to or forming part of this application, is

    to the best of my knowledge true and correct

    f) all development consents required under the Environmental Planning and Assessment Act 1979 for the

    conduct of the service to support this application have been obtained

    g) all site or building plans lodged forming part of this application accurately reflect the premises of the service.

     / /

     Signature of applicant Date

     Under section 253 of the Children and Young Persons (Care and Protection) Act 1998 it is an offence in any application under the Act or regulations to make a statement of furnish information that a person knows to be false or misleading statements. By signing this application you are declaring that the information furnished is to the best of your knowledge true and correct.

    Please send completed form plus all associated documents to:

Director, Central Licensing and Regulatory Support

    Children’s Services Directorate

    Department of Community Services

    Locked Bag 4028

    Ashfield NSW 2131.

    For enquiries, phone 02 9716 2100 or 1800 619 113 or email cslicensing@community.nsw.gov.au CSFL 01 Further licence application Individual non school provider Page 3 of 3 17/09/2009

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