Relinquish License Request

Submit this form if you no longer want to keep your license active and are exempt from licensure.

E-mail Address: *

Prefix: Mr.Mrs.MissMs.Dr.

First Name: *

Last Name: *

License Number: *

Business Name:

Street Address: *

Address Line 2:

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

Postal Code: *

I affirm that I choose to voluntarily reliquish my license because I meet the exemption set forth in NCGS 93D-14. * NoYES

Verification Code:

Enter Verification Code: *

* Required

Thank you for notifying the Board. You will receive email confirmation when you click SUBMIT.

P.O. Box 97833, Raleigh, NC 27624-7833  -  PH: 919.834.3661  -  FAX: 919.834.3665  - Email: info@nchalb.org