255 Capitol St. NE / Child Nutrition Programs
Salem, OR 97310
Scenario 1 – Provider owns the business
Child and Adult Care Food Program
Family Day Care Home Provider Information & Site Application
Sponsoring Organization: ABC, Inc.______Provider Name:____Jane______Doe______
(first name) (MI) (last name)
Provider Birth date:__11/16/1979______/ CNPweb Provider ID:______
CACFP Start Date:__10/1/2013______/ Child Care System ID: ______
Business Owner 1 Information:
Name: _Same as Provider______Birthdate: ______
Mailing Address: 255 Capitol St. NE______
City: Salem______/ State: OR / Zip: 97310______
Phone: 555-123-4567______/ Email:______
Business Owner 2 Information:
Name: Same as Above______Birthdate: ______
Mailing Address: ______
City: ______/ State: OR / Zip: ______
Phone: ______/ Email: ______
Home Information: / State Child Care Approval Information
Bus. Name:Jump Up and Down Daycare
______/ Approval Type: / CCD Registered
CCD Certified
Oregon Department of Education / Office of Learning/Student Services
255 Capitol St. NE / Child Nutrition Programs
Salem, OR 97310
Scenario 2 – Provider does not own the business
Child and Adult Care Food Program
Family Day Care Home Provider Information & Site Application
Sponsoring Organization: ABC, Inc.______Provider Name:____Jane______Doe______
(first name) (MI) (last name)
Provider Birth date:__11/16/1979______/ CNPweb Provider ID:______
CACFP Start Date:__10/1/2013______/ Child Care System ID: ______
Business Owner 1 Information:
Name: _Johnathon Doe______Birthdate: 7/17/1977______
Mailing Address: 123 W. Elm St.______
City: Salem______/ State: OR / Zip: 97310______
Phone: 555-987-6543______/ Email:______
Business Owner 2 Information:
Name: Same as Above______Birthdate: ______
Mailing Address: ______
City: ______/ State: __ / Zip: ______
Phone: ______/ Email: ______
Home Information: / State Child Care Approval Information
Bus. Name:Jump Up and Down Daycare
______/ Approval Type: / CCD Registered
CCD Certified
Oregon Department of Education / Office of Learning/Student Services
255 Capitol St. NE / Child Nutrition Programs
Salem, OR 97310
Scenario 3 – Business owned by nonprofit organization
Child and Adult Care Food Program
Family Day Care Home Provider Information & Site Application
Sponsoring Organization: ABC, Inc.______Provider Name:____Jane______Doe______
(first name) (MI) (last name)
Provider Birth date:__11/16/1979______/ CNPweb Provider ID:______
CACFP Start Date:__10/1/2013______/ Child Care System ID: ______
Business Owner 1 Information:
Name: Montessori Childcare Center/Johnathon Doe (Executive Director) Birthdate: 7/17/1977
Mailing Address: 123 W. Elm St.______
City: Salem______/ State: OR / Zip: 97310______
Phone: 555-987-6543______/ Email:______
Business Owner 2 Information:
Name: Same as Above______Birthdate: ______
Mailing Address: ______
City: ______/ State: OR / Zip: ______
Phone: ______/ Email: ______
Home Information: / State Child Care Approval Information
Bus. Name:Jump Up and Down Daycare
______/ Approval Type: / CCD Registered
CCD Certified