1. 1. From the license applicant, a completed renewal application form as prescribed in R6-6-1101(A) which contains the following information:

   1. a. Personally identifying information, as follows:

      1. i. Name,
      2. ii. Address, and
      3. iii. Phone number.

   2. b. Personally identifying information on the license applicant’s household members, as follows:

      1. i. Name,
      2. ii. Gender,
      3. iii. Age,
      4. iv. Relationship to the license applicant, and
      5. v. School or occupation.

   3. c. Personally identifying information on the license applicant’s children who do not live with the license applicant, including emancipated children, as follows:

      1. i. Name;
      2. ii. Age;
      3. iii. Address; and
      4. iv. Occupation or school, if currently attending.

   4. d. Information about the license applicant, as follows:

      1. i. Any arrest or investigation for a criminal offense, including charge, and arresting agency;
      2. ii. Any referral to or treatment for a psychiatric or psychological problem, including substance abuse, in the last year.

   5. e. Information about the license applicant’s household member, including:

      1. i. Any arrest or investigation for a criminal offense, including charge, and arresting agency;
      2. ii. Any referral to or treatment for a psychiatric or psychological problem, including substance abuse, treatment in the last year.

   6. f. Any current or prior license or certificate held by the license applicant to provide care to a child or adult, as follows:

      1. i. Type of license or certificate;
      2. ii. Date of each license and certificate;
      3. iii. State in which the license or certificate was issued;
      4. iv. Any license or certificate which was revoked, denied, voluntarily surrendered, or suspended and the circumstances; and
      5. v. Name of any other agency with which the license applicant is currently licensed or certified to provide services to children or adults.
   7. g. List of any individuals who live on the property on which the license applicant’s home is located, but not in the license applicant’s home;
   8. h. List of the household members and their relationship to the applicant and to each other;
   9. i. Any changes that should be made to the license conditions;
   10. j. Dated signature.

2. 2. From the license applicant, the items listed in R6-6-1104.03(2)(c),(2)(d), (2)(f), and the following:

   1. a. A completed declaration of criminal history for each new adult household member and, at three-year intervals, a completed declaration for all adult household members;
   2. b. Documentation showing that each new adult household member has been fingerprinted and, at three-year intervals, that all adult household members have been fingerprinted;
   3. c. A physician’s statement every three years from the date of the initial license for the license applicant and all adult household members; and
   4. d. Documentation that the license applicant has completed training as prescribed in R6-6-1105(B).

3. 3. From sources other than the applicant, the documents listed in R6-6-1104.03(3)(d)(i), (3)(e), and (3)(f) and the following:

   1. a. Documentation that each new adult household member has had a criminal history check and that all adults household members have had a criminal history check every three years; and
   2. b. Documentation that the license applicant’s home has passed a health and safety inspection every three years since the date of the initial license.

A license renewal application package is complete when the Division has all the following information:

Historical Note

Adopted effective February 1, 1998 (Supp. 98-1).