NECPA Verification Visit Request NECPA Verification Visit Request FormThe purpose of this form is to notify the NECPA Commission that your program has completed the self-study portion of the NECPA accreditation process and that you are ready to begin scheduling your verification visit. PLEASE SUBMIT THIS FORM TO SCHEDULE A VERIFICATION VISIT.Required Reading to Submit a 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* State License Number*Licensed Capacity*Number of Classrooms*Number of Buildings*Would your program be willing to allow the NECPA to use your verification visit as a training opportunity for NECPA Verifiers?YesNoDays of Operation Select All Monday Tuesday Wednesday Thursday Friday Check all that applyHours of OperationVerification Visit Request Fee*Verification fee for 7-60 Children ($1,155.00)Verification fee for 61-120 Children ($1,265.00)Verification fee for 121-240 Children ($1,375.00)Verification fee for 241+ Children ($1,485.00)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?YesNoAdditional Block Out Date Fee Price: $27.50 Pricing is per EACH additional block out date.How Many Block Out Dates Would You Like to Purchase?12345678910Please List Your Additional Block Dates Requested:Would You Like to Expedite Scheduling to Reduce Scheduling Window?YesNoExpediting this process will shorten your scheduling window from 120 days to 60 days.Expedited Scheduling Fee Price: $550.00 Expediting this process will shorten your scheduling window from 120 days to 60 days.Would you like to expedite your program's results?YesNoExpediting this process will shorten your Council Review and Result timeline to two weeks from the day your visit materials are received at the NECPA Office. Results are issued 8 weeks from the day of the visit if not expedited. Expedited Results Fee Price: $300.00 Receive your results within 2 weeks of your visit materials arriving at the NECPA Office. 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) 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 120 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. 6) 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*Payment DetailsTotal Amount: $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Δ