NBCC Continuing Education Credit Verification
This form should be completed by the continuing education provider and given to the National Certied Counselor
(NCC). This form is only for NCCs who attended a live, in-person continuing education program for which a certicate of
completion was not available. A live program is defined as a real-time, interactive program delivered either in person or
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. Providers Address:
7. Providers Telephone Number: 8. Providers E-mail:
9. Providers Web Site:
10. In addition to this form, the NCC must submit program information that includes course description, program learning
objectives and presenter qualications to NBCC. The NCC must also include a copy of the program brochure or
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 specied 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.