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NAPSEC Membership Application
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Full name
of program: |
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Street
Address: |
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City/State/Zip: |
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Phone: |
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Fax: |
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Web
Site: |
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E-mail
for program: |
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Contact
e-mail for NAPSEC: |
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Director/President/
Principal of program: |
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NAPSEC
contact name: |
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Year founded: |
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Ownership of Applicant (Check One): |
a) Corporation, nonprofit
b) Corporation, for-profit
c) Single Proprietorship
d) Partnership
e) Other
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Name and address of Owner, Partner, or Corporation: |
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List any state agencies that currently license or approve the program
and the date of the last validation. *Please mail NAPSEC a copy
of each. |
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List any national or state organization that has formally accredited
your agency. |
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How did you learn about NAPSEC? If through an individual, please give
individual's name and the name of his/her school: |
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Additional comments or clarifications: |
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Certification of Application
I hereby:
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Apply for membership.
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Grant permission to public licensing agencies, or any other relevant
examining or reviewing agency or group, to release official records and
information concerning the named applicant to NAPSEC for its use, specifically
with regard to consideration of this Membership Application.
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Agree to hold the National Association of Private Special Education
Centers, its Membership Committee and Executive Board, their members,
officers, agents and examiners free from any damage or complaint by reason of
any action they or any of them may take in connection with this application,
the attendant evaluations, an examination or the failure of said Board to
issue a Certificate of Membership.
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Further agree that the application is in compliance with the Civil Rights
Act of 1964.
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Affirm that the agency is in compliance with all applicable local and
state laws and regulations regarding health, safety, fire, and sanitation.
Agree that the named applicant, in order to maintain membership in NAPSEC,
does publicly adhere to and practice the Code of Ethics of the Association as
evidenced by following the Code.
Affirm that the information provided in the application is true and
correct.
Check here if you agree to the above conditions
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