On-line Licensing Application

This form is for first-time applicants with Utah facilities only
(renewal applicants click here).

With submittal of the online application,
please send a check or money order payment of $300 to:
Department of Human Services
Office of Licensing
195 North 1950 West
Salt Lake City, Utah 84116

Enter text for the appropriate fields below and click Submit. Note that only one service type can be selected per application. An additional application must be submitted for each individual site or service requiring licensure.

Organizational Information
Organization:
Address:
City:	State: Zip:
Administrator:
Phone:	Fax:
E-mail:
Licensed Program Information (if different from organization)
Site Name:
Site Address:
City:	Zip:
Site Contact:
Phone:	Fax:
E-mail:
Current Licensor :
Service Type:

Please visit our Preparing for Licensure page for more information on how to prepare your new facility for licensure.