E-mail Address: *
1. Confirm Email Address for Board use: *
2. First Name *
3. Middle Name
4. Last Name *
5. Suffix (Jr. Sr, III, etc):
6. REASON FOR APPLICATION (choose the item that best describes your reason for submitting this application): * (A) I am currently a registered apprentice and have not yet completed the 365-day requirement. I am registering for part of the licensing exam in accordance with 21 NCAC 22F .0104. (B) I am currently a registered apprentice and have completed the 365-day requirement. I am registering for the next available licensing exam in accordance with 21 NCAC 22A .0503. (C) I am currently a registered apprentice and will be retaking part(s) of the exam. (D) I previously completed all apprenticeship requirements, but I do not have a current apprentice certificate. I am registering for the next available licensing exam. (E) I am seeking reinstatement of a suspended or expired license. (F) I am registering to take the next available licensing exam. I qualify to have the one-year apprenticeship requirement waived under 93D-5(c) as follows:
If you selected (F) above, choose one: (i) I hold a permanent license as an audiologist under Article 22 of Chapter 90 of the General Statutes of North Carolina. (ii) I hold a temporary license as an audiologist in North Carolina and have undergone 250 hours of supervised activity fitting or selling hearing aids under the direct supervision of a Registered Sponsor. (iii) I have been continuously licensed to fit or sell hearing aids in another state or jurisdiction for the preceding three years. (iv) I have worked full-time for at least one year in the office of and under the direct supervision of an otolaryngologist fitting or selling hearing aids.
7. PRINTED LICENSE -- Type name exactly as you wish to have it printed on your license: *
8. APPRENTICE CERTIFICATE (if not exempt from apprenticeship requirement, provide certificate number):
9. EXAM REGISTRATION (choose all that apply): * PART A: Simulator (hearing test/audiogram) PART B: Practicum (ear impression on model) PART C: Laws and Regulations PART D: Audiometry, Hearings Aids, and Scope of Practice I have completed one full year of apprenticeship and am eligible under 21 NCAC 22F .0104(d) to take Part D without a fee. I already passed all other parts of the exam. I will be re-testing at least one part of the exam with this registration. This is the first time I have applied to take any part of the exam. This registration is to reinstate an expired license. FEBRUARY EXAM registration MAY EXAM registration AUGUST EXAM registration NOVEMBER EXAM registration
The Simulator and Practicum are scheduled as appointments. Please select your preference for the practicum and simulator portions of the exam: I prefer an early morning time slot (8:30 a.m.). I prefer a late morning time slot (10:30 a.m.). I have no preference.
If you will be sharing a model or traveling with another applicant, please provide name of other applicant so appointments can be scheduled together:
10. Exam Reminders (acknowledge by checking each box): * My preferences above will not guarantee a particular appointment date/time. I am responsible for arranging for a live model for the practicum exam. A two-hour appointment time will be provided by the Board to facilitate scheduling arrangements that the applicant and model may need to make. Applicants taking the Simulator exam will automatically have the practicum scheduled either immediately before or after the simulator test. If I bring a model to the exam who cannot pass the qualifications/otoscopic clearance exam, I understand that a substitute model will not be provided and I will automatically fail the practicum portion of the exam. I can find more information about the exam in the EXAM ISSUES section of the website. The Board does not sponsor or endorse a specific preparation workshop for the exam.
11. ADDITIONAL REQUIRED DOCUMENTS (acknowledge by checking each box): * I understand that the following items shall be submitted in order to complete the application process: Passport style Applicant photograph Audiometer Calibration report, dated within the past 12 months Notarized affidavit (F4-ALER) affirming application Payment of fees -- Exam fee $75, Application fee $425 (Total $500) Background check -- online (use package code "NC16") Verification of Licensure (F7-VOL), if applicable Other supporting documentation for "yes" answers in Qualifications section.
12. ELECTRONIC SUBMISSION PREFERENCE (choose one): I will mail all additional documentation to the Board office. I will electronically submit all additional documentation to the Board by emailing attachments to app@nchalb.org. I have sent Verification form(s) to appropriate state board(s). All other documents will be submitted electronically to app@nchalb.org.
13. PAYMENT * No payment is required for this application under 21 NCAC 22F .0104(d). Corporate office is handling the payment directly. Payment is being sent by mail. Electronic payment will be submitted using the link on the submission confirmation page. Don't know / not sure, but I understand application cannot be processed if payment is not received by the Board within 10 business days after submitting this application (see 21 NCAC 22A .0503). Payment already submitted.
14. EDUCATION INFORMATION (select highest level of education completed): * High School Diploma G.E.D. College (attended, no degree) College degree Graduate School degree
REQUIRED: High School/GED (school name, city, county, state, year completed): *
OPTIONAL: College (School, City, State, Dates Attended (and year graduated), Major, Degree obtained):
OPTIONAL: Graduate School (School, City, State, Dates Attended (and year graduated), Major, Degree obtained):
15. QUALIFICATIONS * Background check will be completed at "www.certifiedbackground.com" using Package Code "NC16" prior to registration deadline. Background check has already been completed within the past 6 months.
15-A. Are you now or have you ever been apprenticed and/or licensed to fit and dispense hearing aids in any other state? * YES NO
If yes, List each state, year(s) licensed, and license number. A verification of licensure form should be sent to each state (F7-VOL).
15B-1: Have you ever made an application for apprenticeship or for a license to fit/dispense hearing aids which was denied? * YES NO
15B-1: If yes, please provide a detailed explanation:
15B-2: 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? * YES NO
15B-2: If yes, please provide a detailed explanation:
15B-3: Has your apprenticeship or license to fit or dispense hearing aids in any other state ever been revoked or suspended? * YES NO
15B-3: If yes, please provide a detailed explanation:
15B-4: 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. * YES NO
15B-4: If yes, please provide a detailed explanation:
15B-5: Have you ever been treated for alcoholism or narcotic abuse? * YES NO
15B-5: If yes, please provide a detailed explanation:
15B-6: Have you ever filed for bankruptcy? * YES NO
15B-6: If yes, please provide a detailed explanation:
15B-7: Have you ever been named as a party in a civil action (legal proceeding)? * YES NO
15B-7: If yes, please provide a detailed explanation:
15B-8: 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? * YES NO
15B-8: If yes, please provide a detailed explanation:
15B-9: 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)? * YES NO
15B-9: If yes, please provide a detailed explanation:
15B-10: Will you be engaged in fitting and selling hearing aids for LESS THAN 27 clock hours per week? * YES NO
15B-10: If yes, please provide a detailed explanation:
16. BUSINESS ADDRESS INFORMATION * Use my business address shown below as my mailing address. I have a different mailing address.
Business Name *
Business Address Line 1 (no PO Box): *
Business Address Line 2 (Suite, etc.):
City *
State *
North Carolina
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, DC
West Virginia
Wisconsin
Wyoming
--U.S. Territories--
American Samoa
Federated States of Micronesia
Guam
Midway Islands
Puerto Rico
U.S. Virgin Islands
Zipcode *
County Code * 000 Unlisted
001 Alamance
002 Alexander
003 Alleghany
004 Anson
005 Ashe
006 Avery
007 Beaufort
008 Bertie
009 Bladen
010 Brunswick
011 Buncombe
012 Burke
013 Cabarrus
014 Caldwell
015 Camden
016 Carteret
017 Caswell
018 Catawba
019 Chatham
020 Cherokee
021 Chowan
022 Clay
023 Cleveland
024 Columbus
025 Craven
026 Cumberland
027 Currituck
028 Dare
029 Davidson
030 Davie
031 Duplin
032 Durham
033 Edgecombe
034 Forsyth
035 Franklin
036 Gaston
037 Gates
038 Graham
039 Granville
040 Greene
041 Guilford
042 Halifax
043 Harnett
044 Haywood
045 Henderson
046 Hertford
047 Hoke
048 Hyde
049 Iredell
050 Jackson
051 Johnston
052 Jones
053 Lee
054 Lenoir
055 Lincoln
056 Macon
057 Madison
058 Martin
059 McDowell
060 Mecklenburg
061 Mitchell
062 Montgomery
063 Moore
064 Nash
065 New Hanover
066 Northampton
067 Onslow
068 Orange
069 Pamlico
070 Pasquotank
071 Pender
072 Perquimans
073 Person
074 Pitt
075 Polk
076 Randolph
077 Richmond
078 Robeson
079 Rockingham
080 Rowan
081 Rutherford
082 Sampson
083 Scotland
084 Stanly
085 Stokes
086 Surry
087 Swain
088 Transylvania
089 Tyrrell
090 Union
091 Vance
092 Wake
093 Warren
094 Washington
095 Watauga
096 Wayne
097 Wikles
098 Wilson
099 Yadkin
100 Yancey
17. MAILING ADDRESS (if different) Use this mailing address only for my exam admission cards and test results. Use this as my permanent mailing address..
Mailing Address Line 1
Mailing Address Line 2 (Suite, Apt, etc):
City
State
NC
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
-Terr.-
AS
FM
GU
MI
PR
VI
Zipcode
18. DULY MADE APPLICATION * I understand that my application will not be processed until it is a Duly Made Application, as defined in 21 NCAC 22A .0401. Failure to submit a "duly made application" by the deadline may result in the applicant being denied admission to the exam (See 21 NCAC 22F .0104).
Verification Code:
Enter Verification Code: *
* Required