Outside The Box Educational Trainings

Renewal Checklist (check boxes that apply to you)

$75 Renewal Fee paid on-line
$25 Late Fee paid on-line
$25 Rush Order Fee paid on-line (FedEx delivery)
*Copy of 30 clock hours per year (mail)
*Last Licensing Visit

Expiration Date on TDC Credential:

Last 4 digits of Social Security:

Name on TDC Credential:

Home Address:

City, State & Zip:

Phone#:

E-mail Address:

Type of program you are working with:

Registered Family Home
Group Child-Care Home
Licensed Child-Care
After School Program
Head Start Program
School District
Other

Business Name:

Business Address:

City, State & Zip

Business Telephone #:

Business Fax #:

Business E-mail Address:

Mail Certificate To:

Home Address
Business Address
E-Mail Address
Other

Enter information if Other or E-Mail Address was selected:

I do hereby certify the above information and attachments are true and correct.

CREDENTIAL AGREEMENT TERMS: Participant agrees to the terms of this credential. The credential is valid for two years from issued date and must send renewal by the expiration date. A $75 Renewal Fee. A $25 Late Fee for renewals received after the expiration date. A $25 Rush Order Fee if requested to over-night a credential certificate. Request for renewal must be received within 6 months of expiration date and must accompany 30 clock hours (10-management (10-child development, 10-child-care choice) and a copy of last licensing visit with no serious deficiencies. Credential will be revoked if participant does not respond or fails to renew at 6 months from expiration date. In addition the following will be grounds for reprimand; if credential holder is placed on probation by licensing or reoccurring serious deficiencies. Three reprimands will lead to credential being revoked. Credential holder will have the right to review if this occurs.

Signature of Statement

I agree.
I do not agree.