Request for Board Certificate to Incorporate

Cost: $50

Please Note

Under G.S. 55B and G.S. 57C, 100% of the membership must be held by a licensee or licensees of the appropriate Board for the same professional services to be rendered in order for the Board to issue the certificate.

Name*

Name of Licensee Forming the Corporation

Prefix First Middle Last

License Number*

Is there a second licensee?*

Yes
No

Name*

Name of Second Licensee

Prefix First Middle Last

License Number*

License Number of Second Licensee

Is there a third licensee?*

Yes
No

Name*

Name of Third Licensee

Prefix First Middle Last

License Number*

License Number of Third Licensee

Mailing Address*

This is where your certificate will be mailed.

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

Who should we contact with questions?*

Prefix First Middle Last

Phone*

Phone number for questions

Please attach a copy of your proposed articles of organization or incorporation

Email print version of completed form

Would you like a PDF version of this completed form emailed to you?*

Yes
No

Email (for PDF delivery)*

Please enter an email address to receive a copy of this completed form.

Request for Board Certificate to Incorporate

Rule changes. Click Here to Review the Temporary Rules for Waivers & Audiology Assistants

Cost: $50

Please Note

Email print version of completed form

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