- Personal Info Form

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CCE/NBCC Greensboro, NC Thursday, April 29, 2010 and Friday, April 30, 2010
Click here to select a different event

Registration Instructions and Customer Support

Please be advised, the information you provide will be transmitted and stored
in a secure environment and used for training and tracking purposes only.

Please note that in order for you to successfully register for your DCC Training date, you will need to complete all
the registration forms in their entirety. There are a total of four pages to complete and the registration process
should take approximately 10 minutes. If for any reason you decide to stop on a form and exit before completing
all pages, you will need to re-register from this page again when you return to the system. Before completing the
registration process please review our Cancellation Policy.

If you have any questions while you are registering, please do not hesitate to contact Customer Support
at (888) 225-8248 or send an email to helpdesk@readyminds.com and we will be happy to assist you.

Personal Information
Note: * Required Fields
First Name: *
MI:
Last Name: *

Address

Address Line 1:*
Address Line 2:
Address Line 3:

City:*		State*:
ZipCode:		Country*:

Home Phone: *

( )

E-mail:*

Alternate Phone:

( )

Fax No.:

( )

Date of Birth:*
(MM/DD/YYYY)

Gender:*

Ethnicity_:

Education*

Master's Degree required

Master's Degrees Earned

Degree*	Institution	Major	Year (YYYY)

Post-Master's Degrees Earned

Degree	Institution	Major	Year

Credential Requirements*
Are you licensed to practice counseling or a related field in the state or country in which you reside or work AND/OR certified in good standing as a National Certified Counselor (NCC) AND/OR hold the RPC with the California Registry of Professional Counselors?
Yes No

If yes, please indicate if you are:
LPC NCC
If another license/certification, please specify:

Please note that CCE will request that you provide proof of licensure or certification when applying for the DCC Credential. It is not necessary to provide this proof at this time. If you answered 'no' to the above question you may still attend the DCC Training and upon successful completion of the training you will receive a formal letter of recognition indicating your participation. If you wish to apply for the DCC credential, within a five-year period you must obtain a professional license to practice counseling or a related field in the State or Country in which you reside or work OR obtain the NCC certification.