NECPA Re-Enrollment Form The purpose of this form is to notify the NECPA Commission that you wish to re-enroll your program in the self-study process for the purpose of renewing NECPA Accreditation. Program Name*NECPA Site Number (8-Digits)*Accreditation Expiration Date Date Format: MM slash DD slash YYYY *If you are re-enrolling less than 1 year prior to the date above, please contact the NECPA Office to review your program’s timeline.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 NumberFax Number (If applicable)Owner NameIs Your Program Center-Based or Home-Based?*Center-BasedHome-BasedAlternate Contact NameAlternate Contact Phone NumberState 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 Re-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 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name