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.

Payment Options*

If mailing in payment and Articles of Organization the address to send it to is: PO Box 16885 Greensboro, NC 27416

Pay Online
Mail in Payment

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.

Total

$0.00

Request for Board Certificate to Incorporate

Proposed Rules, *Revised Policy for Hearing Screening, & Statutory Revisions to Audiology Scope of Practice: Click Here for more Information

Cost: $50

Please Note

Email print version of completed form

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