Expedited Verification Visit Request NECPA Expedited Verification Visit Request FormThis form is to be used by programs that have previously submitted the primary NECPA Verification Visit Request Form for regular scheduling within 120 day window. If you have not submitted the primary form, please click HERE to go to the NECPA Verification Visit Request Form. You will have the option to pay for expedited scheduling on that form page. The purpose of this form is to notify the NECPA Commission that your program would like to expedite the scheduling of your verification visit, reducing your scheduling window from 120 days to 60 days from the date of your request. Program Name* NECPA Site Number (8-Digits)* Program Director Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email Address* Would your program be willing to allow the NECPA to use your verification visit as a training opportunity for NECPA Verifiers? Yes No Days of Operation Select All Monday Tuesday Wednesday Thursday Friday Check all that applyHours of Operation Five Block Out Dates *Block out dates are any days that your program would not be available for a verification visit. You may have five block out days. Days must be listed above in order of preference and may be consecutive or non-consecutive.Expedited Verification Visit Request Fee* Price: Agreements1) I have answered each question in the yellow and blue sections of the Self Assessment Instrument or given a written explanation in the comment section if the question is not applicable to my program. 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 scheduled within 60 days 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 Δ
