Fillable Reinstatement Application (Center for Credentialing & Education)

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Reinstatement Application (Center for Credentialing & Education)

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1
CCE Approved Clinical Supervisor (ACS) Program Reinstatement
Updated July 2020
This application form is interactive.
Download the form to your computer to ll it out.
CCE Approved Clinical
Supervisor (ACS) Program
REINSTATEMENT APPLICATION PACKET
The Center for Credentialing & Education, Inc. (CCE) values diversity.
There are no barriers to credentialing on the basis of gender, race, creed, age, sexual orientation, or national origin.
The CCE Approved Clinical Supervisor (ACS) Program mark is a trademark of the Center for Credentialing & Education, Inc. (CCE).
CCE
and NBCC
®
are registered trade and service marks of the National Board for Certied Counselors, Inc.
3 TERRACE WAY
GREENSBORO, NC 27403-3660 USA
TEL: 336-482-2856 * FAX: 336-482-2852
cce-global.org * cce@cce-global.org
™
CENTER FOR
CREDENTIALING
&
EDUCATION
2
CCE Approved Clinical Supervisor (ACS) Program Reinstatement
Updated July 2020
REINSTATING THE CREDENTIAL
MAINTAINING THE CREDENTIAL
The ACS credential is valid for ve years as long as you comply with CCE policies and procedures. As a credential
holder, you are required to pay annual maintenance fees and recredential at the end of ve years to maintain the credential.
Payment of your annual maintenance fee means you agree to continue to adhere to the ACS Code of Ethics and report any
charge or complaint about a criminal, civil, state board, or other professional disciplinary matter(s) within 60 days of your
knowledge of the complaint or charge.
Annual maintenance fee: Currently $50
You will receive an annual maintenance fee notice approximately six weeks before the credential anniversary date. If you
have any concerns about your invoice, please contact CCE. Please be sure to pay the annual maintenance fee by the due
date in order to maintain active status.
CREDENTIAL REINSTATEMENT
To reinstate your inactive or expired CCE Approved Clinical Supervisor (ACS) credential, you will need to take the
following steps:
• Submit a reinstatement application
• Pay the reinstatement fee (currently $50)
• Pay any past-due fees
• Document 20 hours of continuing education within the past ve years (if credential has expired)
• Accept and sign the Ethics Attestation and Applicant Agreement & Release Authorization
RECREDENTIALING AND CONTINUING EDUCATION
To retain your credential, recredentialing is necessary every ve years. The recredentialing process and its components are
described below:
• ACSs must complete 20 continuing education hours specic to clinical supervision during each ve-year
credential period. You may submit up to nine hours of supervision of your work as a clinical supervisor. You may
be required to provide copies of certicates of attendance and other documentation of continuing education.
• Recredentialing notices and instructions are mailed in conjunction with the annual maintenance fee. Please see the
annual maintenance fee information above for details.
• You must accept and sign the Ethics Attestation and Applicant Agreement & Release Authorization.
3
CCE Approved Clinical Supervisor (ACS) Program Reinstatement
Updated July 2020
CCE ETHICS POLICIES AND PROCEDURES
Applicants and credential holders are responsible for ensuring that their behavior adheres to the standards identied in the
CCE Approved Clinical Supervisor (ACS) Program Code of Ethics.
Whether you are an applicant or credential holder, you are required to disclose any of the following types of matters:
• Criminal charge. (Note: You do not need to disclose trac charges unless they involve drugs or alcohol or injury to
person or property.)
• Legal action related to business or occupational activities in which you are named as a defendant.
• Grievance by any government entity or professional organization.
• Employment termination due to conduct.
• Probation or removal from any graduate program for reasons unrelated to grades.
Written disclosures must be received within 60 days of you becoming aware of the required disclosure, unless you are an
applicant and are disclosing a previously concluded matter. In such cases, the disclosure and required documentation must
be submitted with your application
An applicant must complete all portions of the ACS application, including the ethics attestation and the Applicant
Agreement & Release Authorization. Disclosures and other ethics matters are reviewed in accordance with CCE
procedures. Disclosures do not automatically render an individual ineligible for credentialing. CCE reserves the right to
deny eligibility based on an ethics review. Application fees are not refundable when an application is rejected.
Your disclosure must be submitted in writing with your application. Please seal your written statement and supporting
documentation in an envelope marked “CCE Ethics Department.”
Your written submission must include relevant documentation, including copies of the charges, outcomes, and paperwork
indicating that required actions have been completed. Documentation regarding this varies depending on the type of
matter. Please refer to cce-global.org/Prof/Ethics for samples, answers to frequently asked questions, and policies.
4
CCE Approved Clinical Supervisor (ACS) Program Reinstatement
Updated July 2020
1. First Name, MI:
Last Name:
Previous Name(s):
2. Street Address:
City, State/Province
:
ZIP/Postal Code, Country:
3. Home Telephone: Business Telephone:
Fax:
4 . Email:
 YES  NO
 YES  NO
 YES  NO
Check here if you do NOT want your contact information shared with continuing education providers.
CCE Approved Clinical Supervisor (ACS) Program
REINSTATEMENT APPLICATION FORM
PAGE 1
REF.#: _____________ AMOUNT: __________ BATCH #: __________ DATE: ____________
FOR OFFICE USE ONLY
5. I am interested in volunteering for � marketing eorts � standards development.
If you answered “YES” to any of the above questions, you must include a complete, detailed explanation related to
the response. You must also provide copies of relevant documentation, such as copies of the complaint, pleadings, and
compliance with nal orders.
Place these materials in a sealed envelope marked “Attention: Ethics Department” and return with your application.
Failure to provide required information will delay the processing of your application.
6. Ethics Attestation
Please respond to each statement below.
1. Have you ever been or are you currently charged with a criminal oense?
2. Have you ever been or are you currently a defendant in any type of legal action
related to your business or occupational activities?
3. Have you ever been or are you currently the subject of any complaint matter or
disciplinary review by any government entity or professional organization?
4. Have you ever been terminated or discharged from employment for conduct reasons?
5. Have you ever been placed on probation or removed from any graduate program
in which you were enrolled for reasons unrelated to grades?
 YES  NO
 YES  NO
PLEASE FILL OUT ELECTRONICALLY OR PRINT CLEARLY
5
CCE Approved Clinical Supervisor (ACS) Program Reinstatement
Updated July 2020
Applicant’s Signature Date (mm/dd/yyyy)
Applicant’s Name: Date:
PAGE 2
CCE credential mark and trademark use policy. I understand that credentialing does not create membership in CCE. I
understand that CCE credentialing is personal to me and may not be transferred to another individual or group.
I understand that professional biographical and credentialing data is considered to be public information and will
be made available in response to public inquiries. I agree that data related to my participation in CCE credentialing
may be used for research and statistical purposes.
I recognize that any credentialing granted by CCE does not represent licensure or other authorization to practice
business activities for a fee. I release CCE from all liability and claims arising from any professional activity.
Continuing Education Requirement
By signing this document, I certify that I have completed the 20 continuing education clock hours required for
recredentialing, OR that my status is currently inactive but not expired; therefore, I agree to comply with the
continuing education maintenance requirement.
8. Applicant Agreement & Release Authorization
All information I provide in this reinstatement application, including supporting documentation, is accurate
and complete to the best of my knowledge. If I have knowledge of any changes concerning my responses in this
application, including my responses in the Ethics Attestation, I agree to report this to CCE in writing within 60 days.
I agree that CCE has the right to contact any person or organization regarding this application, and I authorize
the release of any information requested by CCE to verify the accuracy. I understand that all application materials
become the property of CCE and will not be returned.
I understand that credentialing through CCE depends upon my fulllment of all required criteria and compliance
with CCE policies, which include the CCE Approved Clinical Supervisor (ACS) Program Code of Ethics and the
7. All CCE applicants are required to submit written disclosures of any:
• Criminal oense. (Note: You do not need to disclose trac charges unless they involve drugs, alcohol, or
injury to person or property.)
• Legal action related to business or occupational activities in which he or she is named as a defendant.
• Complaint matter or disciplinary review by any government entity or professional organization.
• Employment terminations due to conduct.
• Probation or removal from any graduate program for reasons unrelated to grades.
I have read the reminder of the required disclosures (above) and have submitted the required written disclosures to CCE
if neccessary.
YES NO
CCE Approved Clinical Supervisor (ACS) Program
REINSTATEMENT APPLICATION FORM
6
CCE Approved Clinical Supervisor (ACS) Program Reinstatement
Updated July 2020
PAYMENT VOUCHER
• Please submit payment of past-due balance listed on the ACS late notice in addition to the $50
Reinstatement Application fee.
• All fees must be paid in U.S. dollars. Fees are nonrefundable.
• CCE will review your application packet within six weeks of receipt.
• You will be notied of your status and informed if further information is needed.
REINSTATEMENT APPLICATION FEE: CURRENTLY $50 (plus late fees)
METHOD OF PAYMENT
Telephone: Day:
Evening:
Applicant’s Name:
□ Enclosed is a check or money order payable to CCE in the amount of $_________ (U.S. dollars).
□ Please charge the credit card listed below in the amount of $_________ (U.S. dollars).
Cardholder Signature: ______________________________________ Date (mm/dd/yyyy): ____________
Name on Card:
Card Type:
VISA
MasterCard
American Express
Submit your application and payment
• Mail: CCE; P.O. Box 63223; Charlotte, NC 28263-3223
• Fax: 336-482-2852
If you are mailing your application, be sure to make copies of all your application materials before submitting the
originals. CCE cannot return any forms or documents to you or to a third party.
Account
Number:
Card Security Code (from back of card):
Expiration
Date:
PLEASE FILL OUT ELECTRONICALLY OR PRINT CLEARLY
Check this box and email your application to credentialinfo@cce-global.org. Please note that we cannot take
payment via email. We will reach out to you via email with instructions after you email your application.
If you wish to submit this application via email, DO NOT complete the credit card information on this page.
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Reinstatement Application (Center for Credentialing & Education)

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Completed 26 May 2021

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