NBCC Continuing Education Credit Verification
This form should be completed by the continuing education provider and given to the National Certied Counselor
(NCC). This form is only for NCCs who attended a live, in-person continuing education program for which a certicate of
completion was not available. A live program is defined as a real-time, interactive program delivered either in person or
by
electronic devices that permit the participant to interact with the presenter.
NCC Name: NCC Number:
Continuing Education Provider and Program Information:
1. Name of Continuing Education Program:
2. Date: Time: From To
3. Location: 4. Clock Hours Awarded:
5. Name of Continuing Education Provider:
6. Provider’s Address:
7. Provider’s Telephone Number: 8. Provider’s E-mail:
9. Provider’s Web Site:
10. In addition to this form, the NCC must submit program information that includes course description, program learning
objectives and presenter qualications to NBCC. The NCC must also include a copy of the program brochure or
agenda.
Program Attendance Verification:
Authorized Representative for the Provider
Name Title
I attest that the above-named NCC attended this continuing education program for the hours specied above.
Signature of Authorized Representative Date
NCC Attestation
I attest that the information provided on this form is complete and reflects my attendance at the above-named continuing
education program.
Signature of NCC Date
Upload this form to your CE portfolio at ProCounselor.nbcc.org.
