Professional Development Subscription
Program Order Form – Prepaid
Effective October 1, 2017
Form AP-09-003 (Rev. 1/1/13)
3059 Peachtree Industrial Blvd. ▪ Duluth, GA 30097 ▪ Phone 800-499-9907 ▪ Fax 877-259-1105 ▪ www.cceionline.edu
©Copyright 2011, ChildCare Education Institute. All rights reserved. CCEI provides training and education programs and makes no guarantee of
employment, promotion, or retention.
Center/School/Corp Name: _________________________________________
Primary Contact/Admin: ____________________________________________
City, State, Zip: ___________________________________________________
Alternate Phone: __________________________________________________
Email Address: ___________________________________________________
Start Date: __________ End Date: __________
Center Based Unlimited Annual Subscription Plan
Center Based Licenses (minimum of 20 licenses required)
The disclosure of your Social Security Number is optional. ChildCare Education Institute (CCEI) will use this information only for administrative purposes, as more
See F.A.M.E. Terms and Agreements for program details.
Requires credit card or ACH draft. Delinquency will result in immediate suspension of account privileges and access to system inclusive of transcripts and certificates. A
$50.00 reinstatement fee will be imposed. Any account past due over 60 days will lose the access to the system and no reinstatement will be made.
Professional development, block hour purchases, and subscriptions (individual or center-based) are eligible for refunds within five (5) days of purchase IF no courses
have been accessed. Otherwise, no refunds will be issued. Any violation of the F.A.M.E. or Subscription Terms and Agreement will result in immediate cancellation of
access and no refunds will be given.
Credit Card: VISA Master Card AMEX Discover
By Check: Business Personal
Expiration Date: Security Code:
What made you decide to purchase today? (Please select one): Google Yahoo Bing (MSN) Other Internet Search Engine
Saw TV Ad Saw a Magazine Ad Saw an Internet Ad Received something in the mail Received something via email
Saw you on Facebook Got a call from someone at CCEI Saw you at a trade show Referred by a Friend/Co-Worker
Referred by Employer Referred by NAEYC Connecticut Charts-A-Course Georgia Bright from the Start
Did your employer have any direct contact from CCEI that influenced your decision to purchase this training from CCEI?
Yes (please select one below) No Not that I know of
I, or my employer, received a call from a CCEI admissions representative
I, or my employer, received information in the mail from a CCEI admissions representative
I, or my employer, received an email from a CCEI admissions representative I, or my employer, received a renewal notice
I read information via email in the CCEI newsletter I received an email about something happening at CCEI that prompted me
I received an email with a promotion that prompted me I, or my employer, talked to someone at a trade show
Signature: ______________________________________ Date: ______________________
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