2020 - 2021
Child Care Provider Data Worksheet
Student Parent Name: ___________________________________________________________
The above named student parent has applied for a Child Care Grant at Caldwell Community College and
Technical Institute. The information provided here will be used to help determine eligibility for this grant and
provide the college with the necessary information to add the child care provider as a vendor for payment once
the student is accepted into the grant program.
Name of Child Care Facility: ______________________________________________________
Doing Business as Name (if applicable): _______________________________________________
Contact Person Name: ___________________________________________________________
Billing Address: ________________________________________________________________
City: ____________________________________ State: ________ Zip: _________________
E-mail: _______________________________________________________________________
Telephone Number: __________________ Alternate Phone Number: _____________________
Child Care Provider’s License Number: ______________________________________________
Federal Taxpayer Identification Number (TIN): ________________________________________
Other monthly funding sources parent receives (ex. WOIA, DSS): $_________________________
First and Last Name of Child
Charge per day
(after all other assistance)
Full-Day
Care
Before/After
School Care
Provider Signature: ___________________________________________ Date: _____________
***Attach a copy of your W-9***
Return completed worksheet to:
Caldwell Community College and Technical Institute
Office of Financial Aid
E-mail finaid@cccti.edu
Caldwell Campus 2855 Hickory Blvd., Hudson, NC 28638 Watauga Campus PO Box 3318, Boone, NC 28607
For Office Use Only:
W-9 Received Vendor Number: _______________
click to sign
signature
click to edit
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