2021-2022 NONPUBLIC AGENCY (NPA) PREFERRED PROVIDER APPLICATION
This application is to be completed by CDE-certified NPAs who wish to participate in the Santa Clara County - NPA Collaborative. The collaborative is a partnership between the Santa Clara County Office of Education, the Santa Clara SELPAs I, II, III, IV, VI and the South East Consortium SELPA and member School Districts, and the NPAs for the provision of Special Education Related Services.

By becoming a preferred provider, your agency’s Preferred Status, Master Contract, rate schedule, and contact information will be shared with all participating School Districts in the Santa Clara County.

PLEASE COMPLETE THIS FORM AND UPLOAD A COPY OF THE AGENCY'S CURRENT CDE CERTIFICATION, CURRENT RATE SHEET, CURRENT W-9 and INSURANCE DOCUMENTS TO THE ADDRESS PROVIDED IN THE COVER LETTER.
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Date *
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MM
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Name of Agency *
Application Type *
必須
Contact Name *
Contact Number *
Contact Email *
Ages served in the NPA *
Description of Related Services available *
Please indicate all school districts within the Santa Clara County with whom your NPA is currently under contract *
必須
Has your agency been the subject of a complaint by CDE or OCR in the past 18 months? If yes, please submit redacted copies of the findings in addition to the required documents. *
Non Public Agency Company Name *
Non Public Agency Headquarter's Address *
Contact Person (for questions regarding the application) *
Contact Person's Title *
Contact Person's Office Location *
Contact Person's Telephone Number *
Contact Person's Email *
Person signing the Master Contract once approval is issued *
Title of person signing the Master Contract once approval is issued *
Phone number of person signing the Master Contract once approval is issued *
Email of person signing the Master Contract once approval is issued *
Please check all REQUIRED items being submitted along with this application.  Incomplete application packages will not be accepted. *
必須
* Note for Insurance, including endorsement page
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