Fillable Single Program Application (NBCC | National Board for Certified Counselors)

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Single Program Application (NBCC | National Board for Certified Counselors)

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1
Single Program Application
This application is for live continuing education events only. Submission of a completed application
does not guarantee approval. Application fees are nonrefundable. NBCC will not prereview any
application or program. Incomplete applications will not be considered. Application or program
management cannot be delegated to another entity.
Program Size Definition Fee Submission Requirements
Small Program 17 or fewer sessions or workshops
for review
$300 Application must be received 60
days prior to program date
Large Program 18 or more sessions or workshops for
review
$500 Application must be received 90
days prior to program date
Add Rush Option Providers must pay an additional
“rush” fee for review less than 60 or
90 (as applicable) days prior to the
program date. At least 30 days are
required for a rush review.
Additional
$150 for small
programs
Additional
$200 for large
programs
Applications received less than 60
or 90 days prior to the program date
will incur an additional $150/$200
rush fee. Rush applications must be
received 30 days prior to program
date.
Applications received less than 30 days prior to the program date, regardless of program size, are not eligible for
approval. Application fees are nonrefundable and nontransferable.
Title of Program:
Program Website:
Name of Organization:
Name of Authorized Representative:
The applicant must designate an authorized representative to communicate and cooperate with NBCC concerning
all matters related to the requested single program approval.
Date of Program:
Is this a multisession program? □ Yes □ No Number of Sessions:
If not submitting entire conference for review, application should clearly identify the sessions.
Organization Information
Street Address:
City, State, ZIP Code:
Telephone: E-mail Address:
Number of individual, reviewable sessions or workshops for review:
Preferred method to receive application decision: □ E-mail □ USPS postal mail
REF.#1:____________ BATCH #1: _________
DATE: _____________ AMOUNT:___________
OFFICE
USE
ONLY
2
Providers seeking to offer single programs for NBCC continuing education credit (NBCC credit or NBCC hours) must
satisfy all applicable NBCC Continuing Education Provider Policy (policy) requirements, including all application
requirements and policy terms related to program content, instructors/presenters and provider activities.
Single program providers can offer NBCC credit only for live event programs, including real-time interactive programs
and in-service programs presented in person or by electronic devices that permit the participant to communicate and
interact with the presenter(s) consistent with policy and the directives of NBCC.
(a).
Each single program and application must be reviewed and receive written approval by NBCC prior to being
offered for NBCC continuing education credit. If approved by NBCC, the program may be offered for NBCC
credit for the duration of one year following the approval date, conditioned upon no material change to the
program and compliance with all policy requirements.
(b). Following the expiration or termination of a single program approval, a provider may reapply for approval. In
order to maintain uninterrupted approval, the provider must submit the application at least 60 days prior to the
program approval expiration date, including all required and supporting materials, and all fees and costs related to
the single program application. A rush fee will apply if received less than 60 days prior to expiration.
(c). NBCC retains the sole authority and discretion to approve, reject or condition a single program for continuing
education credit.
Single Program Eligibility Requirements
In order to qualify for single program approval, a provider must satisfy the following program eligibility requirements:
(a). The provider satises all policy requirements, agreements and instructions.
(b). The content and quality of the program satisfy and are consistent with all NBCC policy requirements, agreements
and instructions.
(c). The program presenters satisfy all policy requirements, agreements and instructions, including rules concerning
presenter qualications, knowledge and performance.
(d). The provider designates an authorized representative to communicate and cooperate with NBCC concerning all
matters related to the requested single program approval.
(e). The provider submits a completed and accurate single program application to NBCC, including all required
information, materials and fees. All such application materials become the property of NBCC, and application
fees are not refundable.
Approval Requirements
3
Application Requirements
Incomplete or unsigned applications will not be reviewed. Full and correct payment must accompany the application.
Do not send payment separately.
1. Title of Program:
2. Program Date(s):
3. Target Audience:
4. The maximum number of CE hours available for this program is:
(Do not use the term CEU.)
5. Briey describe the facility in which the program will take place:
6. Is the facility ADA compliant? □ Yes □ No
7. Does the provider maintain policies concerning program fees, refunds and participant cancellation? □ Yes □ No
8. Does the provider maintain a written and published policy concerning the review and resolution of program
participant complaints and disputes related to provider programs? □ Yes □ No
9. Describe the provider’s procedure for verifying attendance:
10. Has the provider ever been denied approval as a continuing education provider or had a program denied approval?
□ Yes □ No
If yes, by which organization(s) was the provider or program denied?
Include with your application:
□ A completed copy of Attachment A.
□ A copy of the proposed brochure or yer advertising the program that includes all information required in
section C.15 of the policy. Identify where the NBCC approval statement will be located. Policy, section C.15 requires:
□ Program registration requirements;
□ Program content description and learning objectives for all sessions;
□ The name and qualications of each program presenter or author;
□ The number of NBCC hours offered for completion of the program; and,
□ The provider contact information, including mailing address, telephone number, e-mail address, and website address.
□ A copy of the agenda for the program.
□ A Presenter Qualication Form for each presenter and a curriculum vitae, résumé or other documentation to verify education,
experience and/or training. The curriculum vitae or résumé must include the presenter’s degree and eld of study. A spreadsheet
may instead be submitted for a large program provided it includes all required information and ts on ledger-sized paper.
□ A copy of the evaluation form that will be used by participants.
□ A copy of the proposed certicate of completion that will be distributed to participants. (See sample.)
Continued on next page.
4
I attest that I have read and understand this application and the NBCC Continuing Education Provider Policy and that
the information provided in this application and the attachments is complete, true and accurate.
Name of Authorized Representative: ____________________________________________________________________
Signature: _____________________________________________________ Date: _______________________________
Send application, required materials and payment to:
NBCC CE Department
3 Terrace Way
Greensboro, NC 27403-3660.
You may also fax the application, required materials and payment form to 336-547-0017 (Attn: CE Department).
Submission of application does not guarantee approval. Applications are reviewed in the order that they are received
unless a rush fee is applied. Review of large program applications submitted with a rush fee is not guaranteed.
Applications received less than 30 days prior to the program date are not eligible for review.
Contact continuinged@nbcc.org with questions.
5
Single Program Application: Attachment A
For multi-session programs, a completed copy of Attachment A must be submitted for each session you wish to have
reviewed. If your program is not multi-session, one copy of Attachment A can be submitted.
Title of Program:
Presenter(s):
Include a Presenter Qualication Form for each presenter and identify who presented what material.
Target Audience:
Number of CE Hours Available:
Describe the program content:
Learning Objectives
1.
2.
3.
4.
Include brochures, agendas, and other promotional materials for the program.
6
Presenter Qualification Form
In order for a provider to offer and issue NBCC continuing education credit, the program must satisfy the following
requirements: the subject matter must be directly and primarily related to an NBCC content area, and the presenter of the
program must qualify as a presenter for the subject matter presented. Qualifying programs must be taught by presenters
who possess appropriate qualications, as required by the NBCC Continuing Education Provider Policy.
Presenter Name:
Current Position Title:
Title of program or session/workshop that he or she will present:
Session Number (if applicable):
The subject matter of this program is directly and primarily related to the following NBCC content area(s) (policy, section G):
Select the presenter category appropriate for this individual (check one):
□ Category 1 Presenter
□ Category 2 Presenter
□ Category 3 Presenter
Degree Major or Field of Study Institution Year
Master’s
Doctorate
Other
Education
Training Relevant to Topic Presented/Authored:
Professional Licenses or Certications:
A curriculum vitae, résumé or other documentation to verify education, experience and/or training must be
attached to this form for each presenter.
7
Sample Single Program Certificate
The sample certicate submitted with your application should meet the requirements set forth in the
NBCC Continuing Education Provider Policy, section I.3:
Live Program Document of Completion Requirements
The Provider must prepare and issue a document of completion (certicate or letter) to each participant completing
a qualifying live, real-time program offered for NBCC credit. Such certicate or letter must include the following
information:
(a). The name and contact information of the Provider;
(b). The title and date of the live program;
(c). The name of the participant to whom the NBCC hours are awarded;
(d). The number of NBCC hours awarded to the named participant;
(e). The name and signature of an authorized representative of the Provider; and,
(f). The NBCC ACEP or NBCC Single Program Provider number.
A certicate or letter verifying program completion must be made available by the Provider to eligible participants
in a timely manner after the conclusion of the program. Such certicates or letters must not be made available prior
to the end of the qualifying program.
8
Single Program Application Payment Authorization
Name of Organization:
Name of Authorized Representative:
Program Size Definition Fee Submission Requirements
Small Program 17 or fewer sessions or workshops
for review
$300 Application must be received 60
days prior to program date
Large Program 18 or more sessions or workshops for
review
$500 Application must be received 90
days prior to program date
Add Rush Option Providers must pay an additional
“rush” fee for review less than 60 or
90 (as applicable) days prior to the
program date. At least 30 days are
required for a rush review.
Additional
$150 for small
programs
Additional
$200 for large
programs
Applications received less than 60
or 90 days prior to the program date
will incur an additional $150/$200
rush fee. Rush applications must be
received 30 days prior to program
date.
Applications received less than 30 days prior to the program date, regardless of program size, are not eligible for
approval. Application fees are nonrefundable and nontransferable.
PAYMENT FORM:
Cardholder Signature: ________________________________________________ Date: ________________________
Daytime Telephone: ___________________________________________ Evening Telephone : ____________________________
Card Number:
Expiration
Date:
Name on Card:
Verication Code Numbers (from back of card):
Card Type:
□ VISA □ MasterCard □ American Express
□ I authorize NBCC to charge the card below in the amount of $________.
□ Enclosed is a check or money order, payable to NBCC, in the amount of $________.
Note: Please write “Single Program Application” on the memo line.
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Single Program Application (NBCC National Board for Certified Counselors)

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Completed 21 July 2020

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