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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.

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 -- $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.

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