Name:
Address:
Daytime Telephone: Certicate Number: Certication Expiration Date:
Please register me for the following NBCC examination:
National Counselor Examination (NCE)—for the NCC certification
National Clinical Mental Health Counseling Examination (NCMHCE)—for the CCMHC certification
2020 NBCC Examination Request Form
for Recertification or Reinstatement
Registration deadline for October Exam: June 12, 2020
Cardholder Signature: ________________________________________________ Date: ________________________
Daytime Telephone: ______________________________ Evening Telephone : ______________________________
Card Number:
Expiration
Date:
Name on Card:
Verication Code Numbers (from back of card):
Card Type: □ VISA □ MasterCard □ American Express
□ Please charge the credit
card listed on the right.
□ Enclosed is a check or
money order payable
to NBCC.
PAYMENT FORM
Amount: $ _________________
SUBMIT YOUR REGISTRATION FORM
• By mail: NBCC; P.O. Box 63160; Charlotte, NC 28263-3160
• By fax: 336-547-0017
FOR OFFICE USE
ONLY
REF.#1:____________
BATCH #1: _________
DATE: _____________
AMOUNT:___________
☐
☐
(Contact NBCC if you are unsure of the past-due amount.)
Examination Fee: $150
Past-Due Fees:
Total:
$
$
I understand that my payment is nonrefundable and my registration is contingent on
available space at my chosen examination site.
Signature:
Date:
