Self Study Review Request

Reminder: This form should be submitted by the designated representative (Accreditation File Builder) for the Organization. You may start the Self Study, save it, and complete it later.

Instructions: Programs must complete the Self-Study Review Request form to either 1) request review of the self-study evaluation and supporting evidence or 2) request extension of time to submit the self-study. The program must request an extension of time if the self-study is not completed within ten months from the date of application. An extension of time fee will apply.

Name of person submitting Self Study *

Title *

Name of Organization *

Physical Address *

City *

State *

Zip Code *

Country

Phone *

Alternate Phone

Email Address *

Fax

Have you submitted the Self Study Evaluation and Evidence? *

Yes

Self-Study Review (Check ONE only) *

Request Review of Self-Study – No charge

Request Extension of Time to complete Self-Study – $365.00

NOTE: This form must be complete and include BOTH today’s date and the date of the program’s current accreditation application. If an Extension of Time is requested, then the program must include the Credit Card Authorization form along with the form. The cost for an extension of time is $365.00 and must be paid in full before this request may be approved.

ALL FEES ARE NON-REFUNDABLE AND NONTRANSFERABLE.

Print Name *

Today's Date *

Title *

Application Date *

Signature *

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