An official website of the State of Louisiana.

Official Louisiana State Websites use .la.gov A .la.gov website belongs to an official
government organization in Louisiana.

Secure .gov websites use HTTPS A lock () or https:// means you've safely
connected to the official .gov website.

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)

Initial Application Renewal Application for License #: Change of Ownership Change of Location

3. FACILITY/AGENCY INFORMATION

Facility/Agency Name:

Location Address: Street, City, State & Zip Code

Mailing Address: Street, City, State & Zip Code

Facility/Agency Telephone #:

Office Telephone Number

Parish:

Facility 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.

Name of Individual:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Individual's Telephone #:

Individual's Date of Birth:

Name of Individual's Spouse: (if applicable)

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Spouse's Telephone #:

Spouse's Date of Birth:

Please select one:

Profit Non-Profit

Federal EIN:

State Tax ID#:

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.)

Name of Partner 1:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Partner 1's Telephone #:

Partner 1's Date of Birth

Name of Partner 2:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Partner 2's Telephone #:

Partner 2's Date of Birth:

Please select one:

Profit Non-Profit

Federal EIN:

State Tax ID#:

Church

Name of Church:

Email Address:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Contact Name:

Please select one:

Profit Non-Profit

Federal EIN:

State Tax ID#:

Corporation/LLC

Name of Corporation:

Email Address:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Contact Name:

Please select one:

Profit Non-Profit

Federal EIN:

State Tax ID#:

Governmental

If governmental, please specify which:

Federal State City Parish

Name of Entity:

Department

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Contact Name:

Please select one:

Profit Non-Profit

Federal EIN:

State Tax ID#:

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:

Individual Ownership

(Please check if this applies)

Individual's Name:

Spouse's Name:

Partnership Ownership:

Partnership Ownership

(Please check if this applies)

Partner's Name:

Partner's Name

Partner's Name:

Church or Governmental entity:

Church or Governmental entity

(Please check if this applies)

Name:

Title:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Date of Birth:

Name:

Title:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Date of Birth:

Name:

Title:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Date of Birth:

Corporation/LLC owned:

Corporation/LLC owned

(Please check if this applies)

Name:

Title:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Date of Birth:

Name:

Title:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Date of Birth:

Name:

Title:

Physical Address: Street, City, State & Zip Code

Mailing Address:

Telephone #:

Date of Birth:

Name:

Title:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Date of Birth:

Name:

Title:

Physical Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Telephone #:

Date of Birth:

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

License Capacity (Proposed, if new facility):

Number of Buildings Used by Children/Youth:

Building Name:

Capacity:

Building Name:

Capacity:

Building Name:

Capacity:

Building Name:

Capacity:

Building Name:

Capacity:

Building Name:

Capacity:

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.

Name: Title, First Name, Middle Name & Last Name

Business Email Address:

Home Address: Street, City, State & Zip Code

Mailing Address: Mailing Address, City, State & Zip Code

Date of Birth:

Telephone #:

Years of Experience in a licensed Facility/Agency:

Date Hired at this Facility/Agency in any Capacity: Format: mm/dd/yyyy

Date Hired as Director/Administrator: Format: mm/dd/yyyy

Director/Administrator responsible for other facilities/agencies?

No Yes

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.

Reference Name:

Mailing Address: Please include Zip Code

Phone Number:

Reference Name:

Mailing Address: Please include Zip Code

Phone Number:

Reference Name:

Mailing Address:

Phone Number:

9. FUNDING SOURCE (Check all that apply)

Department of Children and Family Services (DCFS) Office of Juvenile Justice Private Pay Other (If selected, please indicate below)

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.

Date: Format: mm/dd/yyyy

Electronic Consent

I, agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Type Name and Title

DISCLOSURE FORM FOR BACKGROUND INFORMATION

Name of Facility

Physical Address of Facility/agency: Street, City, State & Zip Code

License number:

1. Has the owner, director/administrator, or any staff ever been convicted of, or pled guilty or nolo contendere to any felony?

Yes No

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?

Yes No

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?

Yes No

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?

Yes No

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?

Yes No

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?

Yes No

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.

Date: Format: mm/dd/yyyy

Electronic Consent

Type Name and Title