EQIT Payment Information Full Name (as you wish it to appear on your certificate)(Required)Personal Phone(Required)Best email to contact you at(Required) Full Personal Address (please include apt/building numbers, etc)(Required) Street Address City State Zip Name of program where you work?(Required)License number of program where you work(Required)Full Business Address (please include apt/building numbers, etc)(Required) Street Address City State Zip Work Phone(Required)Please note: Class materials:1) Will be shipped to the business address unless the participant does not work for a program outside of their personal address. Please make sure the addresses are complete and correct.2) When possible E-mails will be sent to the e-mail address on this document to track these shipments. 3) Additional shipments will require payment of the costs of the materials and shipment to replace lost materials.I confirm that I have read the above information regarding materials(Required) Yes More InformationHow many children under the age of 3 years do your personally care for?(Required)What is your work role?(Required) Family Child Care/Home Based Child Care Teacher, Ages 0 to 3 year olds Director Family, Friend or Neighbor Other Does the program where you work accept CCCAP?(Required) Yes No Is there anything else you would like us to know?Payment OptionsEQIT Class Fee Price: I will be paying by: Credit Card Mailing a Check Paying in person Make checks payable to: United Way of Weld County (ATTN: Alexia Duran) and mail to PO Box 1944, Greeley, CO 80632. Please put in Memo line: 4400 0082 000In person payments accepted at United Way of Weld County office located at 814 9th Street in Greeley. Hours: 9 a.m. – 4 p.m. M-F.Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Δ
