Mother Provider

Military Subsidy Programs
CHILD CARE PROVIDER/PROGRAM INFORMATION AND REGISTRATION FORM
To receive a $25 credit, complete this application online. www.naccrra.org/militaryprograms
NACCRRAMilitary Subsidy Department
1515 N. Courthouse Rd, 11th flr
Arlington, VA 22201
Phone: 1-800-793-0324 x341
Fax: 703-341-4103
Provider/Program Na
(As is appears on license/registration)
Check Any ThatApply:
Nationally accredited program


NAEYC


NAFCC

NAA

NAC

NECPA

CDA credentialed provider

Early Childhood Education or Child Development degreed FCC provider

LicensedProgram


Army After School Program In Your Neighborhood (ASPYN)

Army (ACCYN) program provider working towards accreditation

Marine Corps program provider working towards accreditationAccreditation Expiration Date
Provider/Program Mailing Address:
Street Name and Number
City
State
Zip Code
Address where care is to be provided:
Street Name and Number
City
State
Zip Code
Countyin which care is provided:
Provider/Program telephone number
E-Mail Address:













Contact Name:

Opt Out of Preferred and Approved Provider Network

Type ofProvider/Program (check one):
Center

Family Child Care Home


Group Home

Provider/Program Taxpayer Identification Number (TIN):

Regulatory Status (check one)
Licensed


Regulated

07/01/2009
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DIRECT DEPOSIT ACCOUNT INFORMATION
Attach a voided check for the account designated below.
Bank Name:
Signature:
Automated Clearing House (ACH) Number:
Account Number:
Savings AccountChecking Account
State:
City:

If you choose to use direct deposit for your payments, you will receive a $25 bonus.


Leave this page blank if it is necessary for you to be paid by check.07/01/2009
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(COPY OF LICENSE/ REGISTRATION MUST BE ATTACHED)
Child Care License No. /Registration No.:
Provider/Program Profile
License Expiration Date:
Licensing Agency Contact Phone:...