Materials to Submit with Initial Application – The following materials must

Materials to Submit with Initial Application – The following materials must accompany the initial application for a license: 1. Proof of good standing with the Formation of a Mississippi Nonprofit Corporation with the Mississippi Secretary of State; 2. For-profit applicants must provide information on corporate structure, ownership and proprietary interest; 3. An original copy of the completed application form; 4. An original copy of the letter from the applicant’s Board of Directors authorizing the applicant to sign the application; 5. A list of the titles, names, and term expiration dates of Board members; 6. A statement of purpose that specifies: a. A description of the geographic area to be served; b. The children to be accepted for placement or care (to include age range and gender(s); c. A description of the services to be provided; and d. The program goals and objectives. 7. Verification of six (6) months operating capital, which must not include state funds; 8. Current budget showing both expected expenses and sources of income; 9. Policies regarding fees and charges for services; 10. Staff organizational chart including names of all employees currently holding those positions; 11. A general description of each type of staff position proposed for the Partner Provider detailing qualification requirements, including any necessary credentials; 12. All organizational policy, including but not limited to, the personnel policies and admission/discharge policies; 13. Staff development and training plan that complies with the MDCPS training requirements; 14. Plan for providing care and services; 15. All forms that will be utilized by the Partner Provider, such as an intake application and placement agreement; 16. Certificate of compliance with the civil rights laws; 17. Most recent audit; 18. IRS Form 990; 19. A diagram of all structures of the facility showing compliance with square footage requirements and designated use of each room and location on grounds, any applicable building codes, and evidence of compliance with applicable codes; 20. Proof of fire, sanitation, and other hazardous condition inspections completed within the last three (3) months; 21. Certification of occupancy requirements, elevator inspections, Occupational Safety and Health Administration codes, and all other applicable safety codes; 22. Current emergency policies and procedures for all natural or man-made disasters affecting the facility; and 23. Current insurance policy coverage including but not limited to: a. Auto insurance for staff and volunteers who transport children; b. Comprehensive general liability; and c. Owner property insurance on the facility. The applicant should retain the original copies of all materials submitted unless otherwise denoted above. The applicant should submit only copies of the requested documents unless otherwise denoted above. MDCPS will not be held responsible for loss of originals submitted with application.