Virginia Department of Health Office of Licensure and Certification Application for Abortion Facility Licensure Complete all fields. Incomplete or inaccurate applications will be returned. Any changes affecting the accuracy of the information contained herein must be reported in writing immediately to the VDH Office of Licensure and Certification. Application type: License year: Application is for: Initial Licensure Change of Name License Renewal Change of Ownership Change of Address All sections of this application must be completed for all application types Facility identification Name of abortion facility Main Telephone Number ( ) Street Address Fax ( ) City County State Zip Web Address Federal Employer ID Number: Mailing address (if different from above) City State Zip Administrator of record, if different than owner/operator Name: Title: Telephone Number: ( ) Email Address: Ownership of the facility Owner: Tel. Number: Street Address: Fax Number: City: County: State: Zip: Is any part or program of the abortion facility licensed by another state No Yes agency: If Yes, Agency name: Program/ part:
Virginia Department of Health Office of Licensure and Certification Application for Abortion Facility Licensure Complete all fields. Incomplete or inaccurate applications will be returned. Any changes affecting the accuracy of the information contained herein must be reported in writing immediately to the VDH Office of Licensure and Certification. Application type: License year: Application is for: Initial Licensure License Renewal Change of Address Change of Name Change of Ownership All sections of this application must be completed for all application types Facility identification Name of abortion facility Main Telephone Number ( ) Street Address Fax ( ) City County State Zip Web Address Federal Employer ID Number: Mailing address (if different from above) City State Zip Administrator of record, if different than owner/operator Name: Title: Telephone Number: ( ) Email Address: Ownership of the facility Owner: Tel. Number: Street Address: Fax Number: City: County: State: Zip: Is any part or program of the abortion facility licensed by another state agency: No Yes If Yes, Agency name: Program/ part:
Abortion-Facility-Application.docx