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APPLICATION FOR <br />GROUP CARE FACILITY CERTIFICATE <br />These regulations are applicable to group care facilities housing three (3) or less persons <br />who are unrelated to the proprietor of the establishment [Standard Industrial <br />Classification (SIC) Industry Group # 836; Industry 48361 (Residential Care)] <br />NEW: RENEWAL: AMENDMENT: <br />ANNUAL FEE : $100.00 (FEE SHALL NOT BE PRO- RATED) <br />EXPIRATION DATE DECEMBER 31 OF EACH YEAR. <br />(SUBJECT TO RENEWAL BY 12 /15 OF EA. YEAR) <br />ORDINANCE #: ? ? ? ? ? ? ?? Effective ? ? ? ? ?? <br />- -- PLEASE PRINT LEGIBLY - -- <br />ADDRESS OF FACILITY: <br />FACILITY NAME: <br />OWNER'S NAME <br />MAILING ADDRESS: <br />CITY /STATE /ZIP: <br />CONTACT NUMBER(s): <br />MAXIMUM 4 OF PERSONS HOUSED: <br />