NECPA Verification Cancellation and Visit Reschedule Form The purpose of this form is to notify the NECPA Commission that your program is cancelling a confirmed verification visit and that you request your verification visit to be rescheduled within 120 days of this reschedule request.. PLEASE RETURN THIS FORM TO RESCHEDULE A VERIFICATION VISIT. Please Note: Verification Scheduling: Your program’s rescheduled visit will occur within 120 days (4 months) from the date the NECPA Office receives a Verification Visit Request Form with full payment. National Accreditation Council (NAC) Review: The results of your program’s verification visit will be issued within 60 days from the date of the visit. *Accredited programs should contact the NECPA Office immediately with any concerns about a lapse in accreditation. Program Name* NECPA Site Number (8-Digits)* Accreditation Expiration Date (If Applicable) MM slash DD slash YYYY Enrollment Expiration Date MM slash DD slash YYYY Verification Visit Date to be Cancelled* MM slash DD slash YYYY Program Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Program Director Name* First Last Phone*Program Email Address* Cancellation Fee*30 or more days prior to the scheduled visit date ($75)Less than 30 days prior to the scheduled visit date ($625)Would You Like to Expedite Scheduling to Reduce the Re-scheduling Window? Yes No Expediting this process will shorten your re-scheduling window from 120 days to 60 days.Expedited Scheduling Fee Price: Expediting this process will shorten your re-scheduling window from 120 days to 60 days.NECPA Process Understandings and Agreements1) I have answered ALL questions in the yellow AND blue sections of the Self Assessment Instrument. 2) I have collected surveys from at least 70% of my full and part time staff and 50% of the families we serve. 3) In the event that I place my program’s verification status on hold, any changes to NECPA standards and fees will be applicable to the program at the time of reactivation of the verification visit request. 4) I understand that my visit will be re-scheduled within 120 days (or 60 days if expedited) once the NECPA office receives this form and payment in full. 5) I understand that program cancellations, changes to block out dates, requests to place program on hold, and/or refusal of visit dates are subject to additional fees.Please Print Your Name To Agree To The Stipulations* Payment DetailsFees are non-refundable and subject to change without prior notice.Total Amount $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged. Δ
