Successful Foster Home Licensing in NC - Training Matters

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