Foster Care Licensing - Training Matters
Foster Care Licensing - Training Matters
Foster Care Licensing - Training Matters
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SIGNATURES<br />
I have reviewed and am in agreement with the above information, declare that it is true and accurate, and<br />
understand that according to G. S. 132-1 this information may be furnished to others upon proper request.<br />
Application must be signed by all applicants, social worker, and agency head for licensure to be considered<br />
by the licensing authority.<br />
Type Name of Applicant<br />
<br />
Applicant Signature / Date<br />
Type Name of Applicant<br />
<br />
Applicant Signature / Date<br />
Type Name of Applicant<br />
<br />
Applicant Signature / Date<br />
Type Name of Applicant<br />
<br />
Applicant Signature / Date<br />
Type Name of Social Worker<br />
<br />
Social Worker Signature / Date<br />
Social Worker Phone Number:<br />
Social Worker E-Mail Address:<br />
<br />
Type Name of Agency Director or Designee*<br />
Signature of Agency Director or Designee / Date<br />
*I certify that the Agency Director has appointed me as Designee for the purpose of signing documents for<br />
Regulatory and <strong>Licensing</strong> Services.<br />
DSS-5016 (Rev. 02/10)<br />
Child Welfare Services<br />
14