DHS-7779-ENG (Preliminary Information Form)

License Type

License Holder Lives On-Site

Yes

Is this an emergency relative placement?

Yes

PLACEMENT DATE

HCBS / 245D License Number

HCBS / 245D Name

Click the + button to add an applicant

Applicant

FIRST NAME

MIDDLE NAME

LAST NAME

No middle name

STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTY

Text Box

EMAIL ADDRESS

PHONE NUMBER

IS A PO BOX REQUIRED FOR MAIL DELIVERY

Yes

PO BOX

CITY

STATE

ZIP CODE

Address has been updated to conform to postal standards

Applicant

TYPE OF APPLICANT

Individual

Business/Organization

DOES APPLICANT HAVE A DHS ENTITY ID

Yes

LICENSE HOLDER ENTITY ID

FULL BUSINESS NAME (AS IT APPEARS ON THE FILING WITH MINNESOTA SECRETARY OF STATE)

STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EMAIL ADDRESS

PHONE NUMBER

IS A PO BOX REQUIRED FOR MAIL DELIVERY?

Yes

PO BOX

CITY

STATE

ZIP CODE

Applicant

FIRST NAME

MIDDLE NAME

LAST NAME

No middle name

STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EMAIL ADDRESS

PHONE NUMBER

IS A PO BOX REQUIRED FOR MAIL DELIVERY?

Yes

PO BOX

CITY

STATE

ZIP CODE

CorporateVerifyTxt

Address has been updated to conform to postal standards

Authorized agent

FIRST NAME

MIDDLE NAME

LAST NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

EMAIL ADDRESS

Program / facility information

PROGRAM NAME (DOING BUSINESS AS (DBA) NAME, AS IT APPEARS ON THE FILING WITH THE MINNESOTA SECRETARY OF STATE)

STREET ADDRESS

CITY

STATE

ZIP CODE

COUNTY

EMAIL ADDRESS

PHONE NUMBER

Service Class Description

Agency attestation

I declare under the penalty of perjury that everything I have stated in this document is true and correct. By signing my name in the "Licensor Signature" field, I understand that I am electronically signing this form. I attest and certify that the information provided above is true and accurate. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Stat. §325L.07)

AGENCY STAFF FIRST NAME

AGENCY STAFF LAST NAME

ASSIGNED LICENSOR CODE

EMAIL ADDRESS

PHONE NUMBER

TODAY'S DATE

AGENCY STAFF SIGNATURE

Preliminary Information Form (PIF)

Applicant

Authorized agent

Program / facility information

Agency attestation