Send completed application to:
You may mail or fax in your renewal.
NCCDP National Council of Certified Dementia Practitioners
55 Main Street, Suite 102
Sparta, NJ 07871-1909 USA
Within USA Toll Free 1- 877-729-5191
Membership Services 1.973.860.2245
International Calls 1 973.729.5191
973-860-2244 (fax)
NCCDPCORPORATE@
Certified Dementia Care Manager® (CDCM®) and
Certified Dementia Practitioner® (CDP®)
Renewal Application Form for Both CDP® and CDCM®
If you need CEU’s we have them available through
NCCDP Online University
While certification promotes and maintains quality, it does not license, confer a right or privilege upon or otherwise define the qualifications of anyone in the healthcare field.
If you are a CADDCT you must renew your CADDCT first before renewing your CDCM certification. If you elect to not renew your CADDCT you cannot renew your CDCM.
THIS APPLICATION IS FOR CURRENT CDCM’S and CDP’S WHO ARE RE-APPLYING FOR RENEWAL OF THEIR CERTIFICATIONS. If you have let your certifications expire please contact the NCCDP for instructions.
"NCCDP works to protect your privacy, but we must rely on you to tell us if you have changed your email address or if your email address has been hacked. NCCDP will continue to use the email address that we have on file for you unless we hear from you that it has been changed or hacked."
Note: Your new certification will be emailed to you.
Check here if, your original CDCM® and CDP® certifications were approved by NCCDP as a Golden Living employee. If so by completing this application you are renewing your CDCM® and CDP® certifications only.
Please type or print clearly.
Name (Last, First and Middle) Email Address: Please print clearly
___________________________________________________________ _____________________________________________
Mailing Address: Street Address Home Telephone and Area Code
___________________________________________________________ _____________________________________________
City County State Zip Code Work Telephone
___________________________________________________________ _____________________________________________
Home Phone Number Cell Phone Number
___________________________________________________________ _____________________________________________
Employment & Company Name Your Position / Title
____________________________________________________________ _____________________________________________
Work Address: City County State Zip Code Web Address
___________________________________________________________ _____________________________________________
Personal Email Address Work Email Address
___________________________________________________________ _____________________________________________
What type of community do you work for?
Check: CCRC: ___ Nursing Home: ___ Assisted Living: ___ Residential: ____
Management Company: ____ Other:_____ If, you checked other, please describe: __________________________________________________________________
Do you currently manage or supervise a dementia unit? Yes ___ No ___
If yes, how many beds? _____ Do you supervise staff? Yes ___ No ___
If yes, how many staff do you supervise? _______
I acknowledge that my name will be placed on the NCCDP CDCM® registry located on the web site.
Initial: _____ YOUR ADDRESS WILL NOT BE SHOWN ON THE WEB SITE!
You are required to complete 10 hours of Continuing Education on any health care related topic within 24 months of your renewal date: You can obtain education through Webinars, E-learning, College or Technical Colleges, In-services, seminars, conferences, NCCDP Online University, Alzheimer’s Care Guide magazine. You are not required to mail in the certificates with the CDCM® & CDP® renewal.
Statement that you have completed the required 10 hours of Continuing Education:
I have successfully completed 10 hours of continuing education (any health care related topic) for the last 24 month period for the two year certification since my certificate last renewal. I certify that the information put forth on the CDCM® Certified Dementia Care Manager® & CDP® Certified Dementia Practitioner® renewal / recertification form is true and complete to the best of my knowledge. I further acknowledge that if the information supplied on this form is willfully false, I am subject to disciplinary sanction, including certification suspension/ revocation.
Please sign indicating everything you have stated in the renewal application is true:
Your name: ___________________________________________________________________
Do not send verifying documentation with this form. You are to maintain your certificates of CE or CEU’s for two years following renewal, certificates documenting successful completion of Continuing Education (CE) showing the date and title of the CE program, the number of Continuing Education Units (CEU’s) or contact hours awarded and a certifying signature or other certification of the approved provider. A random audit of CE completion is periodically conducted to verify the preceding statement. The CDCM® / CDP® selected for the audit must provide these original documents to the NCCDP by the deadline specified by the NCCDP audit notice.
All renewals require review and signing a new Instructor agreement and new licensee agreement once you have submitted your renewal.
Your Signature: _________________________________________________________
___ I acknowledge that the License agreement and the Instructor agreements are in effect
Seminar Dates
See train the trainer registration form which you must take prior to taking the CDCM® class. Go to for more information.
Payment Information:
Please renew online or you may mail this form in with your credit card information.
Please Pay Online and Complete Renewal application Online. Once you have completed the renewal process a new certification will be mailed to you with in 4 – 6 weeks.
You do have the option to download this form and mail in.
We accept VISA, Master Card, American Express, Discover and Debit Cards with a VISA / Master Card Emblem. We also accept money orders and personal checks.
Late Fee if your application is not post marked by the time your CDCM® & CDP® expires the late fee is: $35.00
Renewal Fee $250.00 Payment by: Check, Credit Card or Cashier’s Check or Personal check.
Returned Check Fee: $35.00 Replacement fee for lost certificate Fee: $50.00
Please make checks / money order payable to NCCDP.
Mail to: NCCDP 55 Main Street, Suite 102 Sparta, NJ. USA07871-1909
International renewals: Please include a self addressed envelope with postage paid. International orders may only pay by credit card.
If mailing in this form, please mail to the above address. If mailing in the form we recommend that you use FEDEX, UPS or US Postal service requiring a signed receipt.
Credit Card Information:
Name on Card: _________________________________________________________
Check One: Visa: _____ Master Card: ______ AX: ________ Discover: _____________
Number: ________________________________________________ Exp Date: _______
Address where the credit card bill is mailed to: ________________________________________________________________________City:______________________________________State:_________________________
County__________________________________________________________________
Zip Code: _______________________________________________________________
Name that appears on the card: ______________________________________________
EMAIL ADDRESS (required if paying by credit card): __________________________
I would like to order a CDP® pin: Price is $12.00 check here: __________
Check which one applies: GOLDEN LIVING ONLY
I hereby give permission for the NCCDP National Council of Certified Dementia Practitioners to charge my credit card in the amount of $262.00 which includes the CDP pin. Initial Here: ___
I hereby give permission for NCCDP National Council of Certified Dementia Practitioners to charge my credit card in the amount of $285.00 which includes the CDP pin and the $35.00 late fee: Initial Here _____
I hereby give permission for the NCCDP National Council of Certified Dementia Practitioners to charge my credit card in the amount of $250.00 which DOES not include the CDP pin or a late fee: Initial Here ____
Please sign: __________________________________________ Date: ________
IF YOU ARE A CDCM® AND DO NOT WORK FOR GOLDEN LIVING NOR RECEIVED YOUR CDCM® THROUGH GOLDEN LIVING PLEASE SIGN HERE. Your CDP® renewal is included in the Instructor renewal for non Golden Living Employees.
___ $150.00 CDCM only
___ $185.00 CDCM and 35.00 late fee
___ $197.00 CDCM and 35.00 late fee and 12.00 CDP pin
Golden Living Employees Only
___ $250.00 CDCM and CDP
___ $285.00 CDCM and CDP and $35.00 late fee
___ $297.00 CDCM and CDP and $35.00 late fee and $12.00 CDP pin
Please sign: _________________________________________ Date: ___________
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