Childcare Provider Credential Update Request Form
Use this form to request updates to your credential information as a childcare provider. Please complete all sections accurately to ensure prompt processing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization/Facility Name
*
Current Credential Type
*
Please Select
Child Development Associate (CDA)
Associate Degree in Early Childhood Education
Bachelor’s Degree in Early Childhood Education
State Certification
Other
Current Credential Number
*
Requested Credential Change
*
Reason for Update
*
Upload Supporting Documents
Upload a File
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Choose a file
Cancel
of
Submission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Request
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