Form CCEI-SF-EV01 (rev. 3/1/2018)
©
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 866-878-3608 ▪ www.cceionline.com
Copyright 2018, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes
no
guarantee of employment, promotion, or retention.
Mail or fax completed form to:
Compliance
ChildCare Education Institute
3059 Peachtree Industrial Blvd, Suite 100
Duluth, GA 30097
Fax: 866.878-3608
Enrollment Verification Request Form
To be completed by the Student (please type or print legibly)
Please allow ten (10) business days for your request to be processed.
Date of Request: ______________ Student ID: ______________
Student Name: ________________________________________________________
Last First Middle/Former
Address: ____________________________________________________________
Street
____________________________________________________________
City State Zip
Home Phone: (______) ____-______ Daytime Phone: (______) ____-______
Area Code Number Area Code Number
Email Address/User Name:_______________________________________________
Current Certificate Program Name: _______________________________________
Send verification letter to:
___________________________________________________________
Name
___________________________________________________________
Mailing Address
___________________________________________________________
City State Zip
I authorize the release of a letter verifying my enrollment in the online certificate program
named above with ChildCare Education Institute (CCEI) to the address listed above. I
understand a $10 processing fee will be assessed for this request and have provided
payment information.
____________________________________________ _________________
Student Signature Date
Credit Card Authorization:
________________________________
Credit Card Number
____ /____ __________ ___________
Exp. Date CVV Code Billing Zip Code
________________________________
Card Holder’s Name (Please Print)
________________________________
Card Holder’s Signature (Required)
ACH Draft Authorization:
Account Type: Checking Savings
________________________________
Name on the account
________________________________
Routing #
________________________________
Account #
________________________________
Account Holder Signature
For CCEI Internal Use Only:
FAME ID: ________________________
Date Received: ____________________
Verification Fee Paid: _______________
Accounting Representative Signature
Date Letter Mailed: _________________
_______________________________
_ Compliance Coordinator Signature
click to sign
signature
click to edit
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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