Application for License/Exam Registration (F4-ALER)

 

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F4-ALER Affidavit
All applicants must print and submit this affidavit to complete their application.
You can also access the affidavit from your confirmation email or the "Forms/Applications" section of the website.

NOTE:  If you need accommodations due to a disability, in order for you to take the board’s licensing examination, you should submit a written statement with this application that explains your special needs.  The board must also receive (at least 10 working days prior to the licensing examination in question) a signed and dated letter from your health care provider(s) as a medical documentation of your condition, in order to accommodate your documented needs.

 

You will receive immediate email confirmation with a copy of this submission when you click SUBMIT.
Please check your email to verify that application was submitted properly.
You will also be redirected to a confirmation page which has an electronic payment link.

 

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(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:
(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.
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
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.
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.
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 -- $300 exam fee; $250 application fee (Total: $550.00)
Background check -- online (use package code "NC16")
Verification of Licensure (F7-VOL), if applicable
Other supporting documentation for "yes" answers in Qualifications section.
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.
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.
High School Diploma
G.E.D.
College (attended, no degree)
College degree
Graduate School degree
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.
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Use my business address shown below as my mailing address.
I have a different mailing address.

Use this mailing address only for my exam admission cards and test results.
Use this as my permanent mailing address..
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).
Visual Verification Image

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