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Duplicate License or Registration Certificate
Fee: $10
PayPal charges a $2 convenience fee. Your total will be $12.
You may also mail the .pdf copy of this form with payment; or a note with your name, license/registration number, with a $10 check or money order.
Checks/Money Orders are made payable to: NCBOESLPA
Mailing Address:
NCBOESLPA
PO Box 16885
Greensboro, NC 27416
Assistant Information
Your duplicate registration certificate will be mailed to the address on file.
Mailing Address
*
The board has my most up-to-date mailing address that has a mail receptacle. I understand that it will be mailed to the address on file.
Yes, I understand
Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Middle
Last
Registration Number
*
Email (for PDF delivery)
*
Please enter an email address to receive a copy of this completed form. This is not a copy of your license or registration certificate. The license or registration certificate will be mailed to the address on file.
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Duplicate License Fee
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Total
$0.00
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*
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Supported Credit Cards: American Express, Discover, MasterCard, Visa, Maestro
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Expiration Date
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Audiology Assistants Registration
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