Minnesota Licensure Examination Registration Form Page 2
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3MINNESOTA
LICENSURE EXAMINATION REGISTRATION
National Counselor Examination for Licensure and Certification (NCE)
National Clinical Mental Health Counseling Examination (NCMHCE)
ABOUT REGISTRATION
• The cost to register is $195 for either the NCE or NCMHCE. This examination fee is nonrefundable and nontransferable.
• Registration is required. Please allow four weeks’ processing time from the time your fee clears.
• You will be notified of the scheduling process by e-mail once you are registered. You must test within six months of notification unless state
board restrictions apply.
• Send special accommodation requests and registration form to CCE along with supporting documentation from a qualified professional.
PLEASE INCLUDE THE FOLLOWING WITH YOUR MATERIALS:
SEND REGISTRATION MATERIALS TO:
FOR OFFICE USE
ONLY
CCE Assessment Dept.
• Your completed registration form.
P.O. Box 63105
• Your examination fee (Please make check or money order payable to
REF.#1:____________
Charlotte, NC 28263-3105
NBCC.) Use payment form below.
Or:
BATCH #1: _________
• An academic transcript identifying the conferral date of a master’s
Fax: 336-482-2852
degree in counseling or a related field.
DATE: _____________
All of the above must be received before you will be allowed
AMOUNT:___________
to schedule an examination date.
1.
First Name/MI:
Last Name:
Previous Name(s):
2.
Street Address:
City, State:
ZIP Code:
3.
Social Security Number:
4.
Telephone:
(Home)
(Business)
5.
E-mail:
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6.
Gender:
Male
Female
7. Date of Birth (mm/dd/yyyy):
8.
Ethnic Origin
:
(optional; used for statistical purposes only)
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African-American
Asian
Caucasian
Hispanic/Latino
Multiracial
Native American
Native Hawaiian
Other
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9.
Are you requesting special accommodations?
Yes
No
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10. Please indicate which examination you wish to take.
NCE
NCMHCE
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11. Have you previously taken the NCE or NCMHCE?
Yes
No
If “Yes,” indicate date(s):
12. Master’s Degree Granting Institution: _______________________________________________________________________________________
I understand that I am taking the NCE or NCMHCE as part of the Minnesota state licensing requirements and approval to take the NCE or NCMHCE
or the receipt of a passing score does not demonstrate that Minnesota state licensure or NBCC certification requirements have been satisfied. I
authorize CCE to provide the Minnesota Board of Behavioral Health and Therapy with examination results. Use of the NCE or NCMHCE scores for
licensure in other states cannot occur until licensure is granted in Minnesota. By signing this document, I certify that the information provided in this
application is accurate to the best of my knowledge. I agree to abide by all NBCC and CCE policies concerning the NCE and NCMHCE examinations.
Signature: _______________________________________________________ Date: ______________________
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PAYMENT FORM
Card Type:
VISA
MasterCard
American Express
Amount: $ _________________
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Name on Card:
Enclosed is a check
or money order
Expiration
payable to NBCC.
Card Number:
Date:
Verification Code Numbers (from back of card):
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Please charge the
Cardholder Signature: ________________________________________________
Date: ________________________
credit card listed
on the right.
Daytime Telephone: ______________________________
Evening Telephone : ______________________________
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