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

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Cosponsorship Application (NBCC | National Board for Certified Counselors)

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Cosponsorship Application for ACEPs
In a cosponsorship, an ACEP partners with another continuing education provider and uses its
ACEP number and/or NBCC approval information to offer NBCC credit for a CE program. An
ACEP may not loan, lend, sell or transfer its NBCC ACEP number or otherwise permit any
other organization, business or individual to use its ACEP number outside of an
approved cosponsorship. Two or more ACEPS can also cosponsor a program by submitting a
completed application for approval. If the cosponsorship does not include an unapproved
provider, the application fee is waived.
ACEP Information
ACEP Name: ________________________________________________________________ ACEP Number: _______
Street Address: ___________________________________________________________________________________
City, State, ZIP Code: ______________________________________________________________________________
Business Telephone: _______________________ Business Web Site: ______________________________________
ACEP Administrator Name: __________________________________________________________________________
ACEP Administrator E-mail: _________________________________________________________________________
Cosponsoring Organization Information
Cosponsoring Organization Name: ____________________________________________________________________
Contact Person: ___________________________________________________________________________________
Contact Person’s E-mail: _____________________________________ Telephone: _____________________________
Cosponsoring Organization Web Site: __________________________________________________________________
Street Address: ____________________________________________________________________________________
City, State, ZIP Code: _______________________________________________________________________________
The ACEP must submit a separate application for each distinct program pertaining to this cosponsor relationship. If a
single program will be offered multiple times, refer to the pricing options below.
Program Offered
Cosponsorship Fee
1 time
$250
2–5 times
$200 per offering
6 or more times
$150 per offering
Applications are reviewed in the order they are received.
Applications received less than 90 days prior to the
program date are not eligible for review.
Contact
continuinged@nbcc.org with questions.
Only live events will be considered. Incomplete applications will not be accepted. Submission of a completed
application does not guarantee approval. Application fees are nonrefundable.
Send application, required materials and payment form to:
NBCC CE D
epartment
3 Terrace Way
Greensboro, NC 27403-3660.
You may also fax to 336-547-0017 (Attention: CE
Department).
1
Relationship Information
All pr
oposed cosponsorship relationships must be reviewed and approved by NBCC prior to the presentation of a
qualifying cosponsored program for NBCC credit.
Attach a copy of the proposed contract between the ACEP and the cosponsoring organization regarding the specific
program. If not included in the contract, the ACEP must indicate and describe whether the ACEP and/or cosponsor
has or will receive any financial benefit(s) or other benefits related to the program.
Attach the completed Cosponsor Relationship Form outlining the roles and responsibilities of the ACEP and the
cosponsoring organization 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.
Program Information
Program Title: _____________________________________________________________________________________
Presenter Name(s): __________________________________________________________________________________
Attach a Presenter Qualification Form for each presenter.
Describe the program content and learning objectives:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
The maximum number of CE hours available for this program is: ____________________
The scheduled or planned date(s) for the live program is: ____________________________________________________
__________________________________________________________________________________________________
Attach brochures, programs, flyers and all other promotional materials. Identify where the cosponsorship approval
statement will be located. Drafts may be submitted.
Approved Cosponsorship Limitation. NBCC approval of a cosponsorship relationship applies only to the specific qualifying
program identified in the application. No other NBCC approval is issued concerning the cosponsor or cosponsor programs, and the
cosponsor must not state that it is otherwise approved by NBCC.
We have read the NBCC Continuing Education Provider Policy, and the information provided in this
application is accurate. We also confirm that the cosponsoring organization has not been terminated or
sanctioned by NBCC as an ACEP or as a provider of single continuing education programs.
Name of ACEP Administrator: ___________________________________________________________________
Signature: __________________________________________________ Date: _____________________________
Name of Cosponsoring Organization Contact Person:__________________________________________________
Signature: ___________________________________________________ Date:___________________________
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.
Task ACEP
Cosponsoring
Organization
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 the certificate of completion
□
Certificate of completion
distribution
□
Compilation of the participant
evaluation summary
□
Retention of the attendance roster
and evaluations for five years
□
Retention of brochures and program
agendas for five years
□
Adherence to all policies not
otherwise specified above
□
Other:
□
Other:
□
Other:
□
3
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□
□
□
□
□
□
□
□
□
□
□
□
□
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Presenter Qualification Form
In order for an ACEP to offer and issue NBCC continuing education credit, the ACEP must satisfy all requirements set
forth in the NBCC Continuing Education Provider Policy. Qualifying programs must be taught by presenters who possess
appropriate qualifications.
Presenter Name: ____________________________________________________________________________________
Current Position Title: _______________________________________________________________________________
Title of Program to Be Presented: ______________________________________________________________________
_________________________________________________________________________________________________
The subject matter of this program is directly and primarily related to the following NBCC content area(s) (policy, section
G): _______________________________________________________________________________________________
__________________________________________________________________________________________________
Select the presenter category for this individual (check one):
□
Category 1 Presenter
□
Category 2 Presenter
□
Category 3 Presenter
Education
Major or Field of Study
Institution
Year
Master’s
Doctorate
Other
Training Relevant to Topic Presented:
Professional Licenses or Certifications:
4
Cosponsorship Application Payment Authorization
Name of ACEP: ________________________________________________________ ACEP #: ___________________
Name of
ACEP Administrator: _______________________________________________________________________
The A
CEP must submit a separate application for each distinct program pertaining to this cosponsor relationship. If a
single program will be offered multiple times, refer to the pricing options below.
Program Offered
Cosponsorship Fee
1 time
$250
2–5 times
$200 per offering
6 or more times
$150 per offering
The ACEP and ________________________ (cosponsoring organization) plan to offer the specific program
described in this application ______ (number of offerings) times. The authorized/enclosed payment reflects
this.
Enclosed is a check or money order payable to NBCC. (Write “Cosponsorship Application” and include the ACEP
number 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.
Send application, required materials and payment form to:
NBCC CE De
partment
3 Terrace Way
Greensboro, NC 27403-3660.
You may also fax to 336-547-0017 (Attention: CE
Department).
5
This program is being cosponsored by two or more ACEPS and does not include an unapproved provider.
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Cosponsorship Application (NBCC National Board for Certified Counselors)

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Completed 21 July 2020

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