SEY Report

33%

License Application Area*
- Speech-Language Pathology
- Audiology
Applicant Information
Name*
Prefix First Middle Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Home or Personal Phone
Current Employer*

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Supervised Experience Year Setting
Exact name & address of place(s) of supervised experience for this report:*
Add as many rows as necessary
Beginning date for this SEY report*
Date Format: MM slash DD slash YYYY
Ending date for this SEY report*
Date Format: MM slash DD slash YYYY
Supervisor
Name of Supervisor*
Prefix First Middle Last
Supervisor's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Signature of Supervisor
Please print this file from the PDF that is emailed to you and have your supervisor sign here.
Report of On-Site Observations
List below the months, dates within the month, and total # of hours observed*
Month Date(s) Observed Total Hours Observed

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To be completed by the Applicant
I have read and discussed this report with my SEY supervisor and certify that this SEY or SEY portion report is accurate and complete.
Signature of Applicant
Date
Date Format: MM slash DD slash YYYY
Comments
Email (for PDF delivery)*
Please enter an email address to receive a copy of this completed form.
Moving from a Temporary License to a Permanent License
Do you want to move to a permanent license?
- No
- Yes
Payment Options*
- PayPal (A $2 fee will be added for online payments)
- Mail Payment with printed form
Mail payment and completed form to:
NCBOESLPA
PO Box 16885
Greensboro, NC 27416-0885

New licenses and renewal receipts will not be issued until the remitted checks have cleared the bank. The only exceptions are those fees paid with money orders, certified checks or PayPal.
SEY Report
Total
$0.00

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Applicant Information

Month	Date(s) Observed	Total Hours Observed