Salutation		First Name*		Last Name*
E-mail*				Title*
Job Function*	...select one... Executive Mgnt. Admin. Support Multi-site Director Site Director Program Director Direct Line Staff Volunteer		Organization Name*
Site Name*			<<=== (Enter "NA " if single ste organization)
Site Address*				City*
State*				Zip Code*
Telephone*			Ext.	Website
My agency is a PASE member - Yes No DYCD Funding Source (Click all that apply): OST SYEP WIA Beacons Discretionary RHYS CSBG NYCALI BEGIN ISY OSY NDA Literacy Teen Action Immigrant Services As of January 1, 2005, PASE has initiated fees for services, with a discount for Members.

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8/5 -- (OST-SAC19) -- Are Your Documents in Order? How to Maintain your School Age Child Care (SACC) License

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	I AM NOT REQUIRED TO PAY and/or THE TRAINING IS FREE (PASE will confirm this with you at a later date)

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CANCELLATION DEADLINE FOR TRAINING IS 3 DAYS PRIOR TO TRAINING