Application Forms

(1) The application for a license is to be made on forms prepared and supplied to the applicant by the Department. (2) Each application for a license must be submitted in writing, legible, with all the information requested on the application. The information gathered by the Department on the application is needed pursuant to T.C.A. § 33-2-406 to determine the applicant's responsible and reputable character and the applicant's ability to meet the minimum standards for the operation of a facility or service. (3) The information to be supplied to the Department is as follows: (a) The name, address, and other background and identifying information of the applicant; (b) A description of the location, design, and type of facility or service to be licensed; LICENSURE ADMINISTRATION AND PROCEDURES CHAPTER 0940-05-02 (c) The name, address, and other background and identifying information of the person or persons responsible for the operation of the facility or service to be licensed including Social Security number and date of birth, place of residence during the past five years and place of birth, proof of citizenship or evidence of legal immigration status, and criminal background check; (d) Personal character references; (e) The signature of the licensee applicant or of the person charged by the licensee applicant for certifying the correctness and completeness of the application and for ensuring compliance with the licensure rules; and (f) Any such other information as the Department may require.