Green Apple Accreditation of Children's Services

Extension of Time Request

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.

Program Name *

Contact Name *

Contract number *

Email *

Fax

Program Address *

City *

State *

Zip *

Have you submitted the Self-Study Evaluation & Evidence? *

Yes

Self Study Review (Pick ONE Only) *

Request Review of Self Study- $0

Request Extension of Time- $365

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 *

Application Date * +

Today's Date * +

Signature *

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