hhs info

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Licensure and Regulatory Services
255 Rockville Pike, Ste 100
Rockville, Maryland 20850-2368
240-777-3986 Fax 240-777-3088
www.montgomerycountymd.gov/licensure
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PRIVATE EDUCATIONAL INSTITUTION APPLICATION (PEI)
(LICENSES ARE NOT TRANSFERABLE FROM LOCATION TO LOCATION OR PERSON TO PERSON)

TODAY’S DATE____________________

Name of Facility: : _______________________________________________________________________

Address : _____________________________________________________________________
Telephone No: _________________  Fax Telephone : _________________ Federal Tax Identification _______________
 City                                    State                                                     Zip Code  

 

Email Address (Required): ___________________________________________

Mailing Address If Different :_______________________________________________________________________   
 Type of Facility:       Nursery       Kindergarten         Elementary (state grades) ____________
Secondary (state grades) ___________ Post secondary (specify area of instruction) ______________   Tutoring
Vocational (specify dance, arts, etc.)___________________________________________________________          

Owner or Corporation Name: _______________________________________________________________________

Accredited by State Department of Education? Yes No Maximum number of students at any one time: ________
Number of students enrolled: _______ *Do you intend to prepare/serve meals? Yes No

Water Supply: Public 􀂅Private Sewerage: Public Private Days and Hours of Operation: _________

NEW FACILITIES OR CHANGE OF LOCATION FOR EXISTING FACILITIES:

  1. Anticipated date of opening or change of location: _____________________________________________
  2. Person to contact to arrange for an inspection:________________________________________________
  3. Contact’s telephone number:_______________________________________________________________
  4. Attach a copy of the Use and Occupancy permit for school use to this application. To obtain, call the
    Office of Use and Occupancy, 240-777-6300.
  5. Attach a copy of the Fire inspection approval call 240-777-2457 to schedule for a fire inspection with the
    Fire Prevention Bureau/Fire Marshal office.

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Signature: _________________________________________________________________

Title: ______________________________________________________________________

 

Payment Method:   Fee Information: $50.00 per facility

Check    Money Order     Visa     Mastercard       Cash is not accepted     Amount: $_______________

Credit card payments may be faxed to 240-777-4531 (confidential fax line).

Credit Cardholder’s Name: _________________________________________________________________

Credit Card No: _______________________________Exp. Date: ________3 Digit Security Code: _______

I agree to pay the above total amount according to the card issuer agreement.

 Cardholder’s Signature: _______________________________________________________

Submit completed application and application fee to address at the top of the application. Checks or money orders are payable to “Montgomery County, Maryland”.
 

OFFICE USE ONLY

   
Receipt No:  ______________          Amount Paid:  _________________   Date Issued:  _______________
Check No:  ______________ Expires:          _________________   Staff Initials:  ________________