DHS-DCL-200 
                                                                                    GOVERNMENT OF 
THE VIRGIN ISLANDS OF THE UNITED STATES 
 
DEPARTMENT OF HUMAN SERVICES 
BUREAU OF LICENSING 
 
APPLICATION FOR A VIRGIN ISLANDS CERTIFICATE 
TO OPERATE A CHILD DAY CARE FACILITY 
 
 
FOR USE BY DHS ONLY 
 
Application Date__________
 
Date Approved___________ 
 
Date Denied _____________ 
I.      1. Name of Agency: _____________________________________________________ 
         2. Mailing Address: _____________________________________________________ 
         3. Telephone Director: ___________________________________________________ 
         4. Name of Agency Director: _________________    Title: ______________________ 
II.     1. Name of Facility: _____________________________________________________ 
         2. Type of Facility: _____________________________________________________________________________ 
         3. Specific Address: _____________________________________________________________________________ 
         4. Telephone Number: ___________________________________________________________________________ 
         5. Directions to Facility: _________________________________________________________________________ 
             ___________________________________________________________________________________________   
 
III.     1. Type of care:            
  Full Day 
 
  Half Day 
 
 Other: _________________ 
                                   
        
  After School  
   Night-Care  
 
    _________________ 
                                                                                                                                                                 Specify 
          2.  Operation:    Days PER WEEK   M  T  W  T  F  S  S   (Circle each day open)            From_____AM/PM to ______AM/PM  
            3.   Vacation Periods in Year______________________________________________________________________ 
          4.   Proposed Capacity: 
      
   Total Number of Children (Include children of operation and staff)______________ 
                 Minimum Age_________________  
Maximum Age_________________ 
          5.    Proposed number of staff (full-time) _______________ 
 
(Part Time) ________________ 
 
          6.    Fees – Monthly Fee   (Indicate any variations in established fee, for example, for more than one (1) child in  
                 same family.   
                 _________________________________________________________________________________________ 
                 _________________________________________________________________________________________        
                 Registration Fee (if any) $____________ 
 
 
Insurance Fee (if any) $____________