2026 New Member Application

Program/Organization Name

Program/Organization Website

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address for NAPSEC Website Listing (WILL be published)

example@example.com

Name of NAPSEC Primary Point of Contact (will NOT be published)

First NameLast Name

Email Address for Primary NAPSEC Point of Contact (will NOT be published)

example@example.com

Date founded

Population Served

Type of Program (select all that apply)

Total Student/Client Enrollment

Total Staff

Program Description (300 words or less)

0/0310

For-Profit/Nonprofit

Disabilities Served (select all that apply)

Ages Served

Program/Organization Logo

X

Instagram

Facebook

Certification of Application

The undersigned hereby:

Apply for membership.

Grant permission to public licensing agencies or any other relevant examining or reviewing agency or group to release official records and information concerning the named applicant to NAPSEC for its use, specifically with regard to consideration of this Membership Application.

Affirm that that agency is in compliance with all applicable local, state and federal laws and regulations required.

Agree that the named applicant, in order to maintain membership in NAPSEC, does publicly adhere to and practice the Code of Ethics of the Association. This document requires your signature.

Please sign here to affirm application information provided is true and correct.

Name

First NameLast Name

Upon submittion of this application for membership, the NAPSEC offce will review and respond within 10 business days. If you have any questions, please reach out to us directly at napsec@napsec.org. Thank you for your application!

Date