Hurricane Helene Special Waiver Form

Information for individuals completing this form

For those licensees impacted in North Carolina by Hurricane Helene or serving the North Carolina public impacted by Hurricane Helene, please state your question(s) or requests regarding a waiver of the statutory requirements of the practice of Speech-language Pathology or Audiology in or from the state of North Carolina, the Board will respond as soon as possible and may request additional information. If electronic delivery of this form is not possible, you may call the Board at 336-272-1828 x2 and receive assistance filling out the form verbally. The granting of a waiver/allowance will be at the full discretion of the Board in compliance with their statutory and regulatory authority and is not guaranteed.

Licensee/Registrant Name(Required)

Prefix First Middle Last

License number (if applicable)(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position(Required)

Licensee/ Temporary Licensee/ Registrant

Out of State Practitioner

Student/ Applicant

Extenuating circumstance/ hardship(Required)

Please provide an explanation of your extenuating circumstance/ hardship.

Waiver/ allowance requested(Required)

What waiver/ allowance are you requesting.

Signature(Required)

I hereby certify and affirm that the information I have provided is truthful and that my ability to fully comply with statutory and/or regulatory requirements has been severely impacted by Hurricane Helene. I understand that the granting of a waiver/allowance will be at the full discretion of the Board in compliance with their statutory and regulatory authority and is not guaranteed.

Email for PDF delivery of submission

Enter your email address here if you wish to receive a copy of your responses.

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OTC Hearing Aids and "Prescription" Hearing Aids Resource Page view page

Information for individuals completing this form