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NBC Qualified Course Provider Registration
Qualified Course Provider status is valid for the calendar year in which it are approved. The status expires on December 31 and must be renewed each calendar year.
The NBC Qualified Course Provider (QCP) Program opens new connections between your organization and the dental laboratory technology community. NBC QCPs will receive:
• 200 multi-date course approvals
• Access to a shortened course approval request form
• Authorization to use the NBC Qualified Course Provider logo
Plus, NBC QCP courses will be listed with distinction in the Continuing Education provider Directory: a collaborative project between the Foundation for Dental Laboratory Technology and NBC. Find the directory at www.dentallabfoundation.org/CESearch.
I. Course Provider Information
Organization
*
Main Contact Name
*
Prefix
First
Last
Suffix
Main Contact Email
*
Organization Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Phone
*
###
-
###
-
####
Many Qualified Course Provider organizations have multiple team members who work together to provide continuing education programs. Please provide the names and email addresses for any colleagues who should be included in correspondence from the NBC Course Approval Program.
Additional Contact Name
First
Last
Additional Contact Email
Additional Contact Name
First
Last
Additional Contact Email
Additional Contact Name
First
Last
Additional Contact Email
II. Payment Information
Qualified Course Provider Registration Fee
*
$1,950.00 - for NADL member organizations
$3,900.00 - for Non-NADL member organizations
Credit cards will be processed after registration is approved by NBC staff. Discounts will be applied accordingly.
Credit Card Type
*
Visa
Mastercard
American Express
Please only select one.
Credit Card
*
Card Number
Expiration
MM
/
YY
CVV
What is this?
3 or 4 digit number printed on the back/front of your credit card
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Name on Card
*
First
Last
Billing Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Email Receipt?
*
Yes
No
The credit card information provided will not be processed until after NBC staff has approved this registration and applied any appropriate discounts. Your receipt will be emailed at that time.
III. Course Provider Agreement and Signature
Please indicate your understanding of the Qualified Course Provider responsibilities and provide your signature below.
By submitting this registration form, you are acknowledging that Certified Dental Technicians (CDT) and Recognized Graduates (RG) will be eligible to receive continuing education credits for attending NBC approved courses.
*
Yes, I acknowledge
It is your responsibility to report credits on behalf of CDT and RG attendees no later than 15 business days after the course using the NBC CE Reporting Sheet, which will be emailed to you with your course approval information.
*
Yes, I acknowledge
It is your responsibility to provide attendees with NBC certificates of attendance, which will be emailed to you with your course approval information. These certificates provide attendees with documentation for personal records. They are not intended to replace the course providers’ responsibility to report credits on behalf of CDT and RG attendees.
*
Yes, I acknowledge
I certify by my signature that I understand the responsibilities of the NBC Qualified Course Provider and agree to adhere to this information. Additionally, I verify that the information supplied herein is true and complete to the best of my knowledge.
*
Clear
Print Name
*
Date
*
MM
/
DD
/
YYYY
