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You will receive immediate email confirmation with a copy of this submission when you click SUBMIT.
You will also be redirected to a confirmation page.

NOTE: If you are LICENSED under 93D you DO NOT complete this form to become a Registered Sponsor.
THIS FORM IS ONLY FOR Au.D. AUDIOLOGISTS WHO WANT TO REGISTER WITH THE BOARD IN ORDER TO SPONSOR AN APPRENTICE.

E-mail Address: *

1. Confirm Email Address:

2. First Name

3. Middle Name

4. Last Name

5. Suffix (Jr. Sr, III, etc):

6. BUSINESS INFORMATION * Use my business address shown below. I have a different mailing address.

7. Business Name

8. Business Street Address Line 1:

9. Business Street Address Line 2 (if any):

10. City

11. 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

12. Zipcode

13. County Code * 000 Unlisted001 Alamance000 Unlisted001 Alamance002 Alexander003 Alleghany004 Anson005 Ashe006 Avery007 Beaufort008 Bertie009 Bladen010 Brunswick011 Buncombe012 Burke013 Cabarrus014 Caldwell015 Camden016 Carteret017 Caswell018 Catawba019 Chatham020 Cherokee021 Chowan022 Clay023 Cleveland024 Columbus025 Craven026 Cumberland027 Currituck028 Dare029 Davidson030 Davie031 Duplin032 Durham033 Edgecombe034 Forsyth035 Franklin036 Gaston037 Gates038 Graham039 Granville040 Greene041 Guilford042 Halifax043 Harnett044 Haywood045 Henderson046 Hertford047 Hoke048 Hyde049 Iredell050 Jackson051 Johnston052 Jones053 Lee054 Lenoir055 Lincoln056 Macon057 Madison058 Martin059 McDowell060 Mecklenburg061 Mitchell062 Montgomery063 Moore064 Nash065 New Hanover066 Northampton067 Onslow068 Orange069 Pamlico070 Pasquotank071 Pender072 Perquimans073 Person074 Pitt075 Polk076 Randolph077 Richmond078 Robeson079 Rockingham080 Rowan081 Rutherford082 Sampson083 Scotland084 Stanly085 Stokes086 Surry087 Swain088 Transylvania089 Tyrrell090 Union091 Vance092 Wake093 Warren094 Washington095 Watauga096 Wayne097 Wikles098 Wilson099 Yadkin100 Yancey

14. EDUCATION INFORMATION * Au.D. PhD in Audiology

Graduate School (School, City, State):

Year Graduated: *

15. Choose the item that best describes your reason for submitting this application: * (A) I am submitting this and a new Application for Apprentice Registration. (B) I want to register as a Sponsor but do not have a current apprentice. (C) My Registered Sponsor certificate has expired and I need to re-instate it. (D) I am continuing to sponsor a current apprentice and wish to extend my certificate for an additional 365 days.

List names of Apprentices (current and new applications):

16. Type name exactly as you wish to have it printed on your registration card: *

17. MAILING ADDRESS (if different from business address already listed): Use this mailing address only for sending certificate related to this application. Use this as my permanent mailing address for all Board correspondence.

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. PAYMENT (choose one): * Electronic payment by bank draft has already been submitted. Payment already mailed to Board office. Payment will be sent by mail. Corporate office will handle payment of application fee. Send me an invoice so I can make an electronic payment. Don't know / not sure

19. ADDITIONAL DOCUMENTATION FOR SUBMISSION (check each box to confirm): * 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 Verification of Licensure form (F7-VOL) Notarized affidavit affirming information provided in application (F8-RSA) Payment of application fee ($150 per year)

20. ELECTRONIC SUBMISSION PREFERENCE (choose one): All supplemental information, as listed in Q19, will be mailed to the Board office. I will upload some of the additional documentation to this application; the rest will be sent by mail. I am submitting all information electronically (only Form F7-VOL will be mailed by verifying Board).

Attach an Audiometer Calibration Certificate:

Attach a digital photo image for passport photo requirement:

Attach a scanned copy of completed notarized affidavit (F8-RSA)

21. I have a current license as an Audiologist in the state of North Carolina. My license number is: *

Verification Code:

Enter Verification Code: *

* Required