Deferral Verification Visit Request Form NECPA Re-Verification Visit Request FormThe purpose of this form is to notify the NECPA Commission that your program has completed all the deferred items and is ready to begin scheduling your re-verification visit.Required Reading to Submit a Re-Verification Visit Request: Verification Visit Scheduling ProcessProgram Name* NECPA Site Number (8-Digits)* Program Director Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address* Licensed Capacity* Number of Buildings* Number of Classrooms* Five Block Out Dates *Block out dates are any days that your program would not be available for a re-verification visit. You may have five block out days. Days must be listed above in order of preference. The NECPA Office is closed on all federal holidays and will not conduct re-verification visits on these days.Would You Like to Purchase Additional Block Out Dates? Yes No Additional Block Out Date Fee Price: Pricing is for EACH Block Out Date requested. How Many Additional Block Out Dates Would You Like to Purchase?12345678910Please List Your Requested Additional Block Out Dates: Would You Like to Expedite Scheduling to Reduce Scheduling Window? Yes No Expediting this process will shorten your scheduling window from 120 days to 60 days.Expedited Scheduling Fee Price: Expediting this process will shorten your scheduling window from 120 days to 60 days.Please Note: Fees are non-refundable and subject to change without prior notice. All returned checks will incur a $35 fee. As of June 1, 2012 program cancellations, changes to block out dates, requests to place program on hold, and/or refusal of dates are subject to additional fees.Agreements1) Our program has completed the self-study portion of the NECPA Accreditation process, reviewed the deferred items and is ready for the NECPA Commission to begin scheduling a re-verification visit. 2) In the event that I place my program’s re-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. 3) I understand that my re-visit will be scheduled within 120 days once the NECPA office receives this form and payment in full. 4) 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. 5)I have read the Verification Visit Scheduling Process document provided at the top of this form prior to submitting this request.Please Print Your Name To Agree To The Stipulations* Deferral Verification Visit Fee Price: Payment DetailsFees are non-refundable and subject to change without prior notice.Total $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name Δ
