Fillable ACEP Cosponsorship Application (NBCC | National Board for Certified Counselors)

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ACEP Cosponsorship Application (NBCC | National Board for Certified Counselors)

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The ACEP Cosponsorship Application (NBCC | National Board for Certified Counselors) form is 3 pages long and contains:

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  • 81 other fields

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1
Cosponsorshi
p Application for ACEPs
Partnering With Another ACEP
This application allows NBCC Approved Continuing Education Providers (ACEPs) to partner on
a program, using both organizations’ ACEP numbers to offer NBCC credit.
First ACEP Information
AC
EP Name: ___________________________________________________________ ACEP Number: _____________
ACEP Administrator Name: ___________________________________________________________________________
ACEP Administrator E-mail: __________________________________________________________________________
Second ACEP Information
AC
EP Name: ___________________________________________________________ ACEP Number: _____________
ACEP Administrator Name: ___________________________________________________________________________
ACEP Administrator E-mail: __________________________________________________________________________
Program Information
Program Title:______________________________________________________________________________________
Scheduled or planned date(s) for the live program: _________________________________________________________
The following approval statement is required on all promotional materials, program websites, and the certificate of
completion:
[FIRST ACEP NAME], ACEP No. ____, and [SECOND ACEP NAME], ACEP No. ____, are cosponsors of this program. This
cosponsorship has been approved by NBCC. Both ACEPs are responsible for this program, including the awarding of NBCC credit.
Attach the completed Cosponsor Relationship Form outlining the roles and responsibilities of each ACEP and the
identities of the individuals and organizations involved in developing, planning and implementing the program.
Attach a sample of the certificate of completion to be distributed to program participants.
Cosponsorship Fees
For cosponsorship between ACEPs, the application fee is waived.
Rush Fee: Applications submitted less than 90 days before the
event date are subject to a “rush” fee. (Applications must be
received at least 30 days prior to the event.)
$100 Rush Fee
Ap
plications are reviewed in the order received.
Applications received less than 30 days before the
event will not be reviewed.
Incomplete applications will not be accepted. Submission of a completed application does not guarantee approval.
Application fees are nonrefundable and nontransferable.
Send application, required materials and payment form
(if applicable) to:
NBCC CE Department
3 Terrace Way
Greensboro, NC 27403-3660.
You may also fax to 336-547-0017
(Attention: CE Department).
2
Cosponsor Relationship Form
Indicate the parties responsible for the roles and tasks of the ACEP and the cosponsoring organization, including the
identities of the individuals involved in developing, planning and implementing the specific program described in this
Cosponsorship Application. All proposed cosponsorship relationships must be reviewed and approved by NBCC prior to
the presentation of a qualifying cosponsored program for NBCC credit.
Task First ACEP Second ACEP Name of Person Responsible for Task
Program design and development
□
□
Review of program content and
learning objectives
□
□
Review of presenter qualifications
relative to the program content
□
□
Presenter contract(s) and/or hiring of
presenter(s) (if applicable)
□
□
Development of promotional materials
□
□
Location selection
□
□
Certificate of completion development
□
□
Final selection of program
□
□
Distribution of promotional materials
□
□
Registration management
□
□
Attendance verification
□
□
Authorized representative who will sign
certificate of completion
□
□
Distribution of certificates of
completion
□
□
Compilation of participant evaluation
summary
□
□
Maintenance of attendance roster and
evaluations for five years
□
□
Maintenance of brochures and program
agendas for five years
□ □
Adherence to all policies not otherwise
specified above
□
□
I attest that I have read and understand this application and the NBCC Continuing Education Provider Policy and
that the information provided in this application and the attachments is complete. Both ACEPs are responsible for
policy compliance and resolution of issues that may arise relevant to the program.
Name of First ACEP Administrator: ___________________________________________________________________
Signature: _____________________________________________________ Date: _____________________________
Name of Second ACEP Administrator: _________________________________________________________________
Signature: _____________________________________________________ Date: ______________________________
3
ACEP / ACEP Cosponsorship Application Payment Authorization
Name of First ACEP: _______________________________________________________ ACEP #: _________________
Name of Second ACEP: _____________________________________________________ ACEP #: _________________
The ACEP must submit a separate application for each distinct program pertaining to this cosponsor relationship.
Only submit this page if a rush fee applies.
Cosponsorship Fees
For cosponsorship between ACEPs, the application fee is waived.
Rush Fee: Applications submitted more than 30 days but less than
90 days before the event date will be subject to a “rush” fee.
$100 Rush Fee
Enclosed is a check or money order payable to NBCC. (Write “Cosponsorship Application” and include both ACEP
numbers on the memo line.)
I authorize NBCC to charge the credit card below in the amount of $_______________.
Note: Paying the wrong fee or sending payment separately
will significantly delay the processing of your application.
Contact continuinged@nbcc.org
with questions.
Application fees are nonrefundable and nontransferable.
Send application, required materials and payment form to:
NBCC CE Department
3 Terrace Way
Greensboro, NC 27403-3660.
You may also fax to 336-547-0017
(Attention: CE Department).
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ACEP Cosponsorship Application (NBCC National Board for Certified Counselors)

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Completed 22 July 2020

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