Agency Name:

Address:

City / State / Zip Code:

Phone / Fax:

Email Address:

Web Site:

Name of CEO:

Location of Agency Branches:

Current Licenses/Accreditations/Certifications  &  Programs/Agency:
(Check all that apply)

Licensing Body

Type (Lic, Acc, Cert)

State

Residential License

ECFA

Licensed Child Placing Agency Accreditation

COA

Certified Accreditation

Select the membership that applies to you.

Agency Annual Membership Fees
(Based on agency's total annual revenue)

Before
1/1/2009

After
1/1/2009

Less than or equal to $250,000

$250,001 up to $500,000

$500,001 up to $1,000,000

$1,000,001 up to $1,500,000

$1,500,001 up to $2,000,000

Over $2,000,000

Individual Annual Membership Fee
(According to By-Laws Specifications)*

Note: Membership fees will not be pro-rated

*Individual membership is extended to those who subscribe to the Statement of Faith and Mission of NACCFA. These individuals cannot be employed nor affiliated with an organization that qualifies to be an agency of NACCFA. Individual membership dues afford all the benefits and conditions associated with NACCFA. Should the individual become employed or otherwise affiliated with an agency or an organization that qualifies for membership, that membership will be terminated with no refund of any remaining dues.

NACCFA By-Laws, Article III, Section 3.1, Paragraph 3

Once you click on "Submit Application" you will be directed to a payment screen
where you will be prompted to enter your total Membership Fee of $
(You can pay by credit/debit card or with a Paypal account)

After you make your payment, you will be asked to provide the following documents:

Copy of Agency license (or explanation if not licensed)
Copy of Agency By-Laws
Any printed information (brochures, newsletters, etc.) about your agency
Copy of Agency Mission Statement
Copy of Agency's 501(c)3 letter

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National Association of Christian Child and Family Agencies - P.O. Box 71952, Phoenix  AZ  85050  (888) 862-2232
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