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CT Facility Name Change Form

This document is an application for changing a facility's "doing business as" (d/b/a) name or the name of the licensee for a facility regulated by the Connecticut Department of Public Health. It requests the current and proposed new names, the level of care provided, and confirmation that a licensee name change was also filed with the Secretary of State. The administrator must sign that the name change does not reflect an ownership structure change.

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Laura Parka
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90 views1 page

CT Facility Name Change Form

This document is an application for changing a facility's "doing business as" (d/b/a) name or the name of the licensee for a facility regulated by the Connecticut Department of Public Health. It requests the current and proposed new names, the level of care provided, and confirmation that a licensee name change was also filed with the Secretary of State. The administrator must sign that the name change does not reflect an ownership structure change.

Uploaded by

Laura Parka
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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DHSR-LICAPP-001a

Rev.1-12

STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH

FACILITY LICENE & INVESTIGATIONS SECTION

APPLICATION FOR CHANGE IN FACILITY D/B/A NAME OR LICENSEE NAME

Under the provisions of the Connecticut General Statutes and the regulations of Connecticut
State Agencies, application is hereby made for a facility or Licensee name change as specified
herein:

1. _____________________________________________________________________
Facility

_____________________________________________________________________
Address City State Zip Code Telephone

2. Level of Care: ___________________________

3. For d/b/a name changes, provide the following information:

Current facility name: __________________________________________________

New Facility Name: ____________________________________________________

4. For Licensee name changes, provide the following information:

Current Licensee name: ________________________________________________

New Licensee name: ___________________________________________________

Has the change in Licensee name been filed with the Office of the Secretary of State?
[ ] YES [ ] NO

5. I attest that this d/b/a or Licensee name change is a change in name only and does not
reflect a change in the corporate ownership structure of the facility.

_________________________________ ____________________________
Signature of Administrator Date Signed

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