Application for License/Exam Registration

Use this form to register for an exam.

Please review this page with your sponsor to ensure you have all necessary documentation ready prior to completing the electronic form.  The affidavit is the signature page for this application.  Both the sponsor and apprentice must sign an affidavit.  Carefully read the affidavit.  It requires that you affirm your review of North Carolina laws and regulations prior to submitting the registration application.  You may print, sign, and notarize the affidavit before continuing so that it can be submitted electronically with the rest of the registration application. Use this link to review the state and federal laws and regulations:  http://nchalb.org/tab/ruleslist.php

 

SUMMARY OF APPLICATION QUESTIONS

Reason For Application

Applicant Info
Applicant First Name
Applicant Middle Name
Applicant Last Name
Applicant Email Address

Applicant Business Location
Applicant Mailing Address

Payment Options
Options include mailing payment, company making payment, or making an electronic payment with a credit card.

PLEASE NOTE:  The Board does accept credit card payments over the phone.

Exam Options
PART A
PART B
PART C
PART D

Passport Photo Requirement
A digital photo may be submitted if it is a passport-style photo

Audiometer Calibration Certificate
A calibration (current within past 12 months) for each audiometer used in business

Notarized Affidavit
Affidavit must be signed by Sponsor and Applicant
A scanned copy submitted with electronic application is accepted as an original

Other Supporting Documents
You will also have an option to upload documents to your registration application.

PLEASE NOTE:  Any information not submitted electronically as part of application must be received by the Board within 10 business days -- see 21 NCAC 22A .0503(b).

Education Info
Select the highest level of education completed
Required: High School/GED information

Required: Military Program of Training (not applicable if applying as a military spouse)
Required: Experience in fitting and selling hearing aids

Qualifications
1. Have you completed the required background check from Certifiedbackground.com using “NC16” as package code?
2. Are you now or have you ever been apprenticed and/or licensed to fit and dispense hearing aids in any other state?
3. Have you ever made an application for apprenticeship or for a license to fit/dispense hearing aids which was denied?
4. Have you ever taken and failed to pass an examination for issuance of a license to fit or dispense hearing aids in any other state?
5. Has your apprenticeship or license to fit or dispense hearing aids in any other state ever been revoked or suspended?
6. Have you ever been convicted of or forfeited bond in connection with a criminal offense (i.e. misdemeanor or a felony)? Include DUIs and DWIs.
7. Have you ever been treated for alcoholism or narcotic abuse?
8. Have you ever filed for bankruptcy?
9. Have you ever been named as a party in a civil action (legal proceeding)?
10. To your knowledge, has a complaint ever been filed against you (or a company owned by you) with a hearing aid related board or organization, the Federal Trade Commission, or any consumer protection agency?
11. To your knowledge, is there anything that would impair your ability to perform the functions for which you are licensed (such as a physical or mental disability)?
12. Will you be working under the supervision of a Registered Sponsor for less than 27 hours per week?

A detailed explanation is required for any “YES” response to Questions 2-12.
Response may be typed into application or attached as a separate document.

PLEASE NOTE:  Submit confidential documentation directly to the Board.