The National Board for Certied Counselors, Inc. (NBCC) values diversity. There will be no barriers to certication on the basis of gender, race, creed, age, sexual orientation, or national origin.
8/2020
I, ____________________________________________, wish to relinquish
My National Certied Counselor (NCC) credential.
I understand that by relinquishing the NCC, I am
also relinquishing all specialty credentials I hold.
NBCC specialty certications include the CCMHC,
NCSC, MAC, NCCC, and the NCGC. I hereby
request that NBCC remove my name from the
listing of active National Certied Counselors.
Only my specialty credential(s), checked below.
Certied Clinical Mental Health Counselor (CCMHC)
National Certied School Counselor (NCSC)
Master Addictions Counselor (MAC)
National Certied Career Counselor (NCCC)
National Certied Gerontological Counselor (NCGC)
My signature below indicates I understand that by relinquishing my NBCC certication(s), I may no longer use any NBCC
certication designation(s). I also understand that NBCC will release my NBCC examination scores upon written request
and payment of all past due and other required fees. I understand that that this form must be received to complete the
relinquishing process and that certication fees will continue to accrue until this form is received. I also understand that I
must surrender my certicate with this form.
I also understand that if I wish to reinstate my NBCC certication(s), I will be required to follow the current process for
reinstatement.
Signature: _______________________________________________________________ Date: ______________
Past-Due Fees Owed: $ _________
Original Certicate Enclosed?
Yes No
(If “no,” please explain.)
If you are unsure of your NCC status or past-due fees, log in to your ProCounselor account or
contact the Recertication Department at recertication@nbcc.org or 336-547-0607.
REQUEST TO
RELINQUISH CERTIFICATION
This form is interactive. Download the form to your computer to fill it out.
Cardholder Signature: _______________________________________________________ Date: ________________
☐ Enclosed is a check or money order made payable to NBCC in the amount of $
☐ Please charge the credit card as listed below in the amount of $
Card Number::
Expiration Date:
Name on Card:
Verication Code Numbers (from back of card):
Card Type:
VISA MasterCard
American Express
PAYMENT INFORMATION
FOR OFFICE USE ONLY
REF.#:__________ DATE: __________
BATCH#: ________ AMOUNT: ________
If a payment is required and you wish to submit this status change form via email, DO NOT complete the credit card
information on this page.
Check this box and email this form to recertication@nbcc.org. Please note that we cannot take payment via email.
We will reach out to you via email with instructions after receiving your form.
NCC Certication Number: ______________ Email address: ______________________________ Phone Number: __________________________
If no payment is required, you may email your completed form to
recertication@nbcc.org, and must mail your NCC certicate to:
NBCC Recertication Dept.
3 Terrace Way
Greensboro, NC 27403-3660
If a payment is required, mail completed form,
NCC certicate, and past-due fees to:
NBCC Recertication Dept.
P.O. Box 63160
Charlotte, NC 28263-3160
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