Nc Credential Application Form - Division Of Child Development printable pdf download

North Carolina Credential Application

DCD Use Only

WF ID#:

Early Child Care Credential (NCECC), Family Child Care Credential (NCFCCC)

and School Age Child Care Credential (NCSACCC)

PLEASE PRINT or TYPE

A. APPLICANT INFORMATION—Fill in every space or put N/A

Last 4 digits of SSN:

Date of Birth:

Mr./Ms.

Last Name:

First Name:

MI:

Home Mailing Address (including apartment or lot number, if applicable):

Maiden Name:

City:

State:

Zip:

County of Residence:

Home Phone (include area code):

Cell Phone (include area code):

Email Address:

(

)

(

)

B. FACILITY EMPLOYMENT INFORMATION—If you are currently employed in a child care center or family child care

home regulated by the Division of Child Development (DCD) you must provide all of the following:

Facility ID# (on license):

Facility Name:

Facility Address:

City:

State:

Zip:

Facility Phone #:

Date of employment at this facility:

Date Employment ended:

# of hours worked per week on a regular

basis:

0-19

20-40

40 +

(

)

Director

Co-Director

Asst. Director

Family Child Care Home Provider

Lead Teacher

Teacher

Current position at this

facility (check one):

Floater

Program Coordinator

Group Leader

Other: _______________________________________

If you were employed in a different DCD regulated facility at the time you completed the Credential

Facility ID# (on license):

coursework, you must provide all of the following:

Facility Name:

Date of employment (

Date Employment ended:

# of hours worked per week on

at this facility)

a regular basis (check one):

0-19

20-40

40 +

C. EDUCATIONAL BACKGROUND—

Check all that have been completed. Attach official transcripts.

High School Info

High School Diploma

Adult High School Diploma

GED

Year graduated from HS or

(REQUIRED

Currently Enrolled

None

GED Program:

AA/AAS

BA/BS

MA/MS

Ed.D./Ph.D.

Program

Major:

College:

Are you currently enrolled in a North Carolina Community College Early Childhood curriculum program?

Yes

Name of North Carolina Community College:

If all or part of your educational expenses have been paid by a scholarship, please check all that apply:

TEACH

Center Paid

CDA

Grant

Other:

D. COURSE INFORMATION: R

ead the instructions for Section D. before proceeding!

Course

Name of NC Community College

Date Course

# of Hrs.

Date of Enrollment

Instructor’s Name or Signature

Grade

Code

where coursework completed

Completed

Absent

(mm/dd/yy)

EDU 111

EDU 112

EDU 113

EDU 119

EDU 145

EDU 235

EDU 263

Note: Successful completion of the credential coursework in regard to the certificate is determined by the NC Division

of Child Development and is subject to laws, rules & regulations in effect upon completion of individual courses.

I understand that approval of my credential certificate is conditional upon, but not limited to, successful completion of

the coursework and receipt of a high school diploma or GED.

***Check for accuracy, sign and date your application. Mail completed application with official

transcripts. (see address on bottom of page 2) Please allow 8-12 weeks to receive your certificate.***

I attest to the accuracy of the above information. This statement must be signed and dated by applicant.

Applicant’s Signature: ___________________________________________________________

Date: ___________________________

North Carolina Division of Child Development REV 4/09

1 of 2

DCD 0168

Nc Credential Application Form - Division Of Child Development

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