Please type in the following information, print out this application form and send in the
completed form along with dues payment and all accompanying documents to:

NAPSEC, 1522 K Street, NW, Suite 1032, Washington, DC 20005

Fax 202.408.3340

If you have any questions email napsec@aol.com

Full Name of Agency:
 

Address:
 

City, State, Zip Code: 

   Telephone and Fax Numbers:  
       Phone:   

            Fax:

 Name of Chief Executive Officer:
 

 Contact E-mail Address:
 

 School Web Site Address:
 

To whom should NAPSEC mailings be sent: 

Ownership of Applicant (Check One):
        a)  Corporation, nonprofit

        b)  Corporation, for-profit 

        c)  Single Proprietorship 

        d)  Partnership

        e)  Other

Name and address of Owner, Partner, or Corporation:

Where applicable, list any state agencies that currently license or approve the program and the date of the last validation (enclose a copy of each).

List any national or state organization that has formally accredited your agency.

How did you learn about NAPSEC? If through an individual, please give individual's name and the name of his/her school:

Certification of Application

The undersigned hereby:

Apply for membership.

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.

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.

Further agree that the application is in compliance with the Civil Rights Act of 1964.

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.
 

Signed: _____________________________________Date: _______________
              (Chief Executive Officer/Director)

Type name and title:

Name of agency:

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