MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION RESIDENTIAL PROGRAM UNIT APPLICATION FOR LICENSE AMENDMENT-RESIDENTIAL TREATMENT AGENCY FOR CHILDREN AND YOUTH
LEGAL NAME OF AGENCY	TELEPHONE NUMBER
ADDRESS (STREET NUMBER, CITY, COUNTY, ZIP CODE)
We hereby make application to the Children's Division, Department of Social Services, for an amendment to the current License to Operate a Residential Treatment Agency for Children and Youth. Please amend the current Residential Treatment Agency for Children and Youth license to change the following (check all that apply):
CHECK	AMENDMENT TYPE	CHANGE	REQUIREMENTS
NEW SITE	ADDRESS	Approved: Fire and Safety Inspection Sanitation Inspection Food Service Letter of Approval for Zoning Program description if different from present program
CAPACITY	GENDER	AGE RANGE
CHANGE CAPACITY	CAPACITY	Approved Fire and Safety Inspection
NAME CHANGE	NAME	Copy of the amended Articles of Incorporation Copy of the amended By-Laws
CHANGE GENDER SERVED	GENDER	Statement of which facility will be used for each gender Staffing plan Program changes resultant from change of gender Staff training plan
CHANGE AGE RANGE SERVED	AGE RANGE	Statement of which facility will be used Staffing Plan Program changes resultant from change of age
ADDRESS CHANGE (Same Location)	ADDRESS
ADD SPECIALIZED CATEGORY OF CARE	CATEGORY	Program changes resultant from adding a different specialized category of care
OTHER (Explain):
NOTE: Any person who violates any applicable provision of Sections 210.481 to 210.536, or who for himself or for any other person makes materially false statements in order to obtain a license or the reveal thereof shall be guilty of a Class A Misdemeanor.
I certify the information provided with this application and attachments to be true:
SIGNATURE OF DIRECTOR OR BOARD CHAIR ►	DATE
TITLE