APPLICATION FOR LICENSE TO OPERATE A JUVENILE DETENTION FACILITY

1. IMPORTANT UPDATES

A License is required PRIOR to opening. Refer to applicable standards for required fees. All fees are to be paid by CERTIFIED CHECK OR MONEY ORDER made payable to the Office of Juvenile Justice. Do NOT send cash, business or personal checks. Fees are NON-REFUNDABLE. All application sections must be completed in their entirety.

2. TYPE OF LICENSE

(Check One Only) Please select at least one option

3. FACILITY/AGENCY INFORMATION

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This field is required Street, City, State & Zip Code
This field is required Street, City, State & Zip Code
Please provide a valid number
Please provide a valid number
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Please provide a valid email address (may list multiple email addresses)

4. ORGANIZATIONAL STRUCTURE

Check only one organization structure (individual, partnership, corporation/LLC or governmental):
Individual Individual – Sole proprietor or sole owner is the individual who directly owns a facility/agency without setting up or registering a corporation/LLC, partnership, etc.
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Please select one:
Partnership Partnership – any general or limited partnership licensed or authorized to do business in the state. Owners of a partnership are its limited or general partners and managers of thereof. (If additional partners, attach separate list to application.)
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Please select one:
Church
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Please select one:
Corporation/LLC
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Please select one:
Governmental
If governmental, please specify which:
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Please select one:

5. CRIMINAL BACKGROUND CHECKS AND STATE CENTRAL REGISTRY

REQUIRED DOCUMENTATION OF STATISFACTORY CRIMINAL BACKGROUND CHECKS AND STATE CENTRAL REGISTRY CLEARANCES MUST BE ATTACHED FOR ALL OWNERS (AS DEFINED ACCORDING OT THE RESPECTIVE REGULATIONS FOR YOUR PROGRAM) AND THEIR NAMES LISTED BELOW.
Individual Ownership: (Please check if this applies)
Partnership Ownership: (Please check if this applies)
Church or Governmental entity: (Please check if this applies)
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Corporation/LLC owned: (Please check if this applies)
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Street, City, State & Zip Code
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Effective October 1, 2018, if an individual is registered as an officer of the board with the Louisiana Secretary of State and/or is listed on the Licensing application, but is not consider to be an owner for licensing purposes according to the respective regulations for your program, a signed, dated approved attestation form shall be submitted attesting to such.

6. PROGRAM INFORMATION

NOTE: IF MORE THAN ONE FACILITY, PROGRAM, OR AGENCY IS TO BE LICENSED, A SEPARATE APPLICATION MUST BE COMPLETED FOR EACH LICENSE REQUESTED.
I/We hereby apply to be licensed as:
Juvenile Detention

7. FACILITY/AGENCY DIRECTOR/ADMINISTRATOR

DOCUMENTATION OF A SATISFACTORY CRIMINAL BACKGROUND CHECK AND STATE CENTRAL REGISTRY CLEARANCE MUST BE ATTACHED FOR THE INDIVIDUAL LISTED BELOW. DIRECTOR/ADMINISTRATOR MUST MEET THE QUALIFICATIONS PRIOR TO BEING APPOINTED. DOCUMENTATION MUST BE SUBMITTED TO THE LICENSING SECTION TO VERIFY THAT QUALIFICATIONS ARE MET. 
 
The facility/agency’s director/administrator – the individual who is responsible for the day to day operation, management, and administration of the facility/agency as recorded with the Licensing Section.
Title, First Name, Middle Name & Last Name
Street, City, State & Zip Code
Mailing Address, City, State & Zip Code
Director/Administrator responsible for other facilities/agencies? If yes, list facilities/agencies below:

8. PERSONAL CHARACTER REFERENCES FOR DIRECTOR/ADMINISTRATOR

(REFERENCES SHALL NOT BE RELATED TO DIRECTOR/ADMINISTRATOR) 
 
THIS SECTION IS TO BE COMPLETED FOR ALL INITIAL APPLICATIONS AND WHENEVER THERE IS A CHANGE IN DIRECTOR/ADMINISTRATOR. PLEASE LIST A MINIMUM OF THREE REFERENCES.
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9. FUNDING SOURCE (Check all that apply)

Please specify other funding source

10. DECLARATION STATEMENTS – CERTIFICATION BY OWNER OR DIRECTOR/ADMINISTRATOR REQUIRED

I understand that a licensing inspection will be made by the Licensing Section, the State Fire Marshal, the Office of Public Health, and other local agencies as may be appropriate (Zoning, City Fire, etc.) 
ALL AGENCIES MUST GIVE THEIR APPROVAL PRIOR TO LICENSURE AND OCCUPANCY.
 
I certify that I have personally completed this application and have carefully investigated all facts necessary to complete this application. I further certify that all information contained in this application is truce and correct to the best of my knowledge and ability. I understand that knowingly providing false informaiton on t his application may cause the application to be denied or the licesne revoked or not renewed. Ifurther understand that failure to provide complete informaiton may result in the application being delayed, denied or the license revoked or not renewed. I also inuderstand that kowingly providing false informaiton may result in criminal charges. I understand that failure to comply with the law and regulations governing the licensure of juvenile detnention facilities could result in the application bieing denied or license being revoked or not renewed.
Please provide the month, day, and year in 2 digits, 2 digits, and 4 digits respectively
Electronic Consent Please select at least one option
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DISCLOSURE FORM FOR BACKGROUND INFORMATION

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This field is required Street, City, State & Zip Code
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1. Has the owner, director/administrator, or any staff ever been convicted of, or pled guilty or nolo contendere to any felony? Please select at least one option
If your answer is “Yes”, please provide the name of the person, person’s position, the offense convicted of/pled to, the date of the offense, the city and state where the offense occurred, the court handling the case, the date of the conviction/plea, and the sentence imposed.
2. Has the owner, director/administrator, or any staff ever been convicted of, or pled guilty or nolo contendere to any misdemeanor involving a juvenile, elderly, or infirm victim? Please select at least one option
If your answer is “Yes”, please provide the name of the person, person’s position, and the offense convicted of/pled to, the date of the offense, the city and state where the offense occurred, the court handling the case, the date of the conviction/plea, and the sentence imposed.
3. Has the owner, director/administrator, or any person named on the application ever used, been known by, any name other than the listed, including any maiden name, former married name, legally changed name, or alias? Please select at least one option
If your answer is “Yes”, please provide the present name of that person, each other named used, the dates that other name/names were used, and the reason for the name change (e.g., marriage, divorce, court-approved name change, etc.).
4. Has the owner, director/administrator, an staff, or affiliate as defined in the minimum standards ever had a license to operate any type of child care facility, residential home, maternity home, juvenile detention facility, or child placing agency denied, revoked, suspended, or not renewed? Please select at least one option
If your answer is “Yes”, please provide the name of the person, person’s position at the time of denial/revocation/suspension/nonrenewal and person’s current position, the name of the facility or agency, the date of the license denial, revocation, suspension, or non-renewal, the type of adverse action involved (e.g., license denial, license revocation, license suspension, license not renewed), the name of the regulatory agency or court taking the adverse action, the city and state where the regulatory agency or court is located, and the reasons given by the agency/court for its action.
5. Has the owner, director/administrator, or any staff ever been denied approval, or had approval denied, revoked, suspended, or not renewed, to serve as a foster or adoptive parent? Please select at least one option
If your answer is “Yes”, please provide the name of the person, person’s position, the date of the denial, revocation, suspension, or non-renewal, the type of adverse action involved (approval/licensure not renewed), the name of the regulatory or court taking the adverse action, the city and state where the regulatory agency or court is located, and the reasons given by that agency/court for its action.
6. Has the owner, director/administrator, or any staff ever been the subject of a validated complaint of abuse, neglect, and/or exploitation of any elderly or inform person? Please select at least one option
If the answer is “Yes”, please provide the name of the person, person’s position, and disposition of the case.
I certify that I have personally completed the Disclosure Form. I further certify that I have carefully investigated all facts necessary to complete the Disclosure Form, and that all information contained on the Disclosure Form, may cause the application to be denied, license revoked or not renewed. I further understand that failure to provide complete information may result in the application being denied or my license revoked, or not renewed. I also understand that knowingly providing false information may result in criminal charges. I understand that failure to comply with the law and regulations governing the licensure of specialized programs or juvenile detention facilities could result in the application being denied or licensed revoked.
Please provide the month, day, and year in 2 digits, 2 digits, and 4 digits respectively
Electronic Consent Please select at least one option
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