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For BHA-Budget&Finance Use Only <br /> Date Received Amount Received$ Check Number Initials <br /> Date Application Materials Forwarded to DBHR <br /> For DBHR Use Only <br /> Certification Number: <br /> State of Washington <br /> Department vices i Department of Social and Health Services <br /> AHealthSer%%cs Behavioral Health Administration <br /> Transforming rive: Division of Behavioral Health and Recovery <br /> INITIAL APPLICATION FOR BEHAVIORAL HEALTH AGENCY LICENSURE <br /> AND <br /> CERTIFICATION FOR MENTAL HEALTH, SUBSTANCE USE DISORDER, <br /> AND/OR PROBLEM AND PATHOLOGICAL GAMBLING SERVICES <br /> WAC 388-877-0305 AGENCY LICENSURE-APPLICATION <br /> SECTION I: INITIAL APPLICATION FOR <br /> BEHAVIORAL HEALTH AGENCY LICENSURE <br /> Agency Ownership name: <br /> If your agency is a public Agency,please indicate the name of the tribal,federal,state,county,or municipal government,health <br /> district,or educational service district under which the agency will operate. <br /> If your agency is a corporation, partnership,or sole proprietor or other privately-owned agency,please indicate the entity or firm <br /> name listed on your Washington State Master Business License (you must use this entity or firm name as your agency name.) <br /> Uniform Business Identification Number(UBI) <br /> Enter your Washin ton State Uniform Business Identification Number(UBI See Chapter 70.60 RCW) <br /> AGENCY NAME, Line 1: This is the name under which you provide certified services,and it will be listed in Directory of <br /> Licensed and Certified Behavioral Health Agencies in Washington State (Directory). Note:The name of the agency must be <br /> the same as the firm or registered trade name and address listed on your Washington Business License. <br /> AGENCY NAME, Line 2 (IF ANY): This name is published directly under the Agency Name in the Directory. <br /> Ownership Application Materials <br /> All applicants must submit the following with this application: <br /> ❑ A copy of the report of findings from a criminal background check of any owner of 5 percent or more of the organizational assets. <br /> ❑ A copy of the agency's business license from the Department of Revenue that authorizes the organization to do business in <br /> the state of Washington. <br /> ❑ An application fee of$1,000. The fee amount must be in the form of a check or money order payable to the Department of Social <br /> and Health Services(see address at the end of this form). <br /> END OF SECTION l:INITIAL APPLICATION FOR BEHAVIORIAL HEALTH AGENCY LICENSURE <br /> Revised 10/5/17 Page 1 of 8 <br />