Welcome to NYSSACC!!!
New York State School-Age Care Credential Renewal Application
This application should be filled out ONE YEAR prior to the expiration date on your certificate. Once your application has been received you will be sent a packet of materials explaining how to go about renewing your credential.
Name
Social Security Number
Address
City
State
Zip code
Day Phone (including area code)
Night Phone (including area code)
E-Mail Address Birth Date: Month/Date/Year
Place of Employment
Dates of employment
Zip Code
Supervisors Name
Phone Email
Agency that taught your Credential Preparation program:
Date of original Credential Award:
To the best of my knowledge, the above information is true, I understand that there will be a $150 renewal fee that is payable upon submission of the packet of materials that I will be receiving after I submit this application, further, I understand that this can be applied for through EIP or I can pay for it myself.” By typing your name and date in the boxes below, you are indicating that you have read and understand the above statement.
Signature: Date:
Please check here if you need an EIP Application include in your packet: Select One Yes No
