Texas Dept of Family
and Protective Services / GOVERNING BODY/ADMINISTRATOR OR EXECUTIVE DIRECTOR DESIGNATION / Form 2819
October 2012
“Texas law gives you the right to know what information is collected about you by means of a form you submit to a state government agency. You can receive and review this information, and request that incorrect information about you be corrected by contacting your licensing representative.”

SECTION A - GOVERNING BODY DESIGNATION

Name of Operation: / Operation Number:
Address:
Governing Body or Organization Name / Telephone Number (A/C)
FULL. LIC. ISSUED
Address: Street City State Zip
Print the Name of Chief Executive Officer or Head of the Governing Body / Telephone Number (A/C)
Mailing Address: Street City State Zip
Name of Designee of Governing Body: / Telephone Number (A/C)
FULL. LIC. ISSUED
Mailing Address: Street City State Zip

I hereby designate the person stated above as official representative (designee) to speak for and act on our organization’s behalf.

  • I understand that as the permit holder, the governing body is ultimately responsible for maintaining compliance with the childcare licensing law and minimum standards.
  • I understand that all waivers and variances must be requested and signed by me or by the designee.
  • I understand that anytime there is a change in the designee of an operation, the governing body is responsible for notifying the licensing division.
  • I understand that the licensing division will notify the governing body and all controlling persons of compliance documentsand remedial action against the operation.

Authorization:

Chief Executive Officer, Head of Governing Body or Each Partner (Signature) / TitleDate
SECTION B - ADMINISTRATOR/EXECUTIVE DIRECTOR DESIGNATION
I (we) hereby designate / as administrator OR executive director of
located at

Authorization:

Signature of Chief Executive Officer, Head of Governing Body or Each Partner, or Designee / Title / Date

FORM 2819

FORM INSTRUCTIONS

GOVERNING BODY/ADMINISTRATOR OR EXECUTIVE DIRECTOR DESIGNATION

PURPOSE OF THIS FORM

This form is an optional form to assist residential operations in reporting changes.

To identify the person appointed by the governing body of a residential operation that is not a sole

proprietorship to act for the governing body in a specified capacity. The “designated representative” or

designee is the person assigned by the governing body to speak for or act on its behalf.

To designate an administrator of a residential child-care operation, in writing, as required by TAC §748.307(3) and §749.507(2). Independent foster homes may also use this form to notify DFPS of a change in the executive director.

PROCEDURE

Section A – The governing body completes and submits to licensing each time the operation appoints a designee.

Section B – The operation completes and submits to licensing each time the governing body designates an administrator or executive director of a residential operation.