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, ________________________________________, hereby request that NBCC change the active status of my NCC
certication and specialty certications (if applicable) to retired status. My signature below attests to the following:
1. I am not currently employed as a professional counselor nor do I perform volunteer work in which I am designated
a counselor.
2. I have read and agree to adhere to the guidelines for the retired status option.
3. I understand this status change will also apply to any specialty certications that I hold.
4. I understand that if I return to counseling practice of any type, I must have my NCC status changed to accurately
reect my practice or relinquish my certication entirely.
5. I understand that if I allow my certication to lapse, I will be required to reinstate my certication. (Information
regarding NBCC’s reinstatement process can be found at ProCounselor.NBCC.org.)
6. I will continue to adhere to the NBCC Code of Ethics.
7. I will disclose to NBCC any charge, complaint, or conviction about a criminal, civil, state board, or other
professional disciplinary matter(s) within 60 days of occurrence.
8. I understand that all status change procedures and policies are subject to change.
9. I understand that retired status follows a one-year certication cycle, and I must pay a reduced annual certication fee.
10. I understand that in order to change my certication status, my account must be current on fees and I cannot be the
subject of any ethics review.
REQUEST FOR
“RETIRED” STATUS CHANGE
This form is interactive. Download the form to your computer to fill it out.
Signature: ________________________________________________ Date: ____________
NBCC certication number: _________ Email address: __________________ Phone number: ____________________
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.
If no payment is required, you may email your completed form to
recertication@nbcc.org, or mail your completed form to:
NBCC Recertication Dept.
3 Terrace Way
Greensboro, NC 27403-3660
If a payment is required, mail your completed
form and past-due fees to:
NBCC Recertication Dept.
P.O. Box 63160
Charlotte, NC 28263-3160
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: ________
Past-Due Fees Owed: $ _________
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.
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