NECPA Enrollment Form Program Name*Street Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this also your shipping address?*YesNoShipping Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Director* First Last Program Email Address* Phone Number*Fax Number (If applicable)Owner Name*Is Your Program Center-Based or Home-Based?*Center-BasedHome-BasedAlternate Contact Name*Alternate Contact Phone Number*State License Number*Please Upload a Copy of Your State License*Accepted file types: jpg, gif, png, xlsx, xlx, csv, pdf.License Capacity*Number of Classrooms*Number of Buildings*Is your program working with a third-party consultant during the self-study phase?*YesNoConsultant Name First Last Consultant Email NECPA Enrollment Fee*Application Fee for 7-60 Children ($350.00)Application Fee for 61-120 Children ($375.00)Application Fee for 120-240 Children ($450.00)Application Fee for 241+ Children ($500.00)Select Your License Capacity TierAdditional Products Select All Additional NECPA Self Assessment Instrument (One copy is included with application fee) Additional NECPA Standards Book (One copy is included with application fee) Additional Documentation Box Labels (One set is included with application fee) Parent Flyers (Flyer designed to acquaint parents with the accreditation process and its value, 25 per order) Agreements1) I understand that the NECPA accreditation is valid for three years with the submission of an Annual Report during each of the accreditation years. 2) I understand that a NECPA Accredited program is required to maintain NECPA standards, requirements and physical plant under which the program is awarded accreditation. 3) I understand that the NECPA Commission reserves the right to revoke the accreditation of any program found to be out of compliance with the NECPA standards. 4) I understand that the re-enrollment period lasts for two years from the date of the NECPA Enrollment Letter issued by the NECPA Office and that the NECPA Verification Visit Request Form must be submitted within that time period. 5) I understand that a NECPA accredited program is asked to request a verification visit at least 8 months prior to the accreditation expiration date to prevent a lapse in accreditation. 6) I understand that a NECPA accredited program is asked to request a verification visit at least 8 months prior to the accreditation expiration date to prevent a lapse in accreditation.Please Print Your Name To Agree To The Stipulations*Payment DetailsTotal Amount $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Δ