Agreement to one of the following. E-Mail: XX.XXXXXXX@XXX.XX.XXX Fax: (000) 000-0000
Agreement to one of the following. E-Mail: XX.XXXXXXX@XXX.XX.XXX Fax: (000) 000-0000 Mail: Missouri Department of Social Services – Children’s Division Child Care Provider Relations Unit, XX Xxx 00, Xxxxxxxxx Xxxx, XX 00000 The undersigned hereby agrees to provide the services and maintain compliance, pursuant to the requirements of this document. Upon receiving a certificate of registration, a binding agreement shall exist between the provider and the Department of Social Services. ________________________________________________________________ _____________________________________________________________________ Authorized Signature of Director/Owner/Board Chair Printed Name and Title ____________________________________________________________ ____________________________________________ ___________ _________________ Address Where Care is Provided City State Zip ___________________________________________________________________ ____________________________________________________ ________________________________________ County Where Care is Provided Phone Number Alternate Phone Number _____________________________________________________________ ____________________________________________ ___________ _________________ Physical Address of Facility City State Zip _____________________________________________________________ ____________________________________________ ___________ _________________ IRS Form 1099 Xxxxxxx Xxxxxxx (Xxxxxxx xx Xxxxxx) Xxxx Xxxxx Zip ______________________________________________________ ________________________________________ _______________________________________________ E-mail Address (Required) SSN or FEIN MO Professional Development Registry ID# (MOPD ID) Child Care Facility is Exempt from Licensure Due To: (CHECK ONLY ONE BOX): Child Care program operated by a Religious Organization. Nursery School Public School Business RETURN ONLY THIS PAGE OF THE AGREEMENT TO THE CHILDREN’S DIVISION. 1 Introduction and Background Information The Missouri Department of Social Services (Department) hereby enters into this agreement for the purchase of child care services for authorized clients of the Department, in accordance with the provisions and requirements stated herein.
