Mailing List Request

Cost: $50 each
Please note that lists will be sent in Microsoft Excel format.
What is in the mailing list?
Names, mailing addresses, field of practice, license number, issue date, expiration date, and status (Temporary or Permanent).
Name of Company/ Individual Requesting List*
Email*
Please enter an email address to receive a copy of this completed form and mailing list.
Which list(s) do you want?*
- SLP
- Audiology
- Both
Payment Options*
- PayPal (A $2 fee will be added for online payments)
- Mail Payment with printed form
Mail Payment with Printed Form*
I understand that if I select "Mail Payment with printed form". I will print off the PDF sent to the email provided and include it with my payment when I mail it to the Board.
- I understand!
Total
$0.00
Payment Method*

American Express
Discover
MasterCard
Visa
Maestro
Supported Credit Cards: American Express, Discover, MasterCard, Visa, Maestro
Card Number Expiration Date Security Code Cardholder Name
Checks/money orders are made payable to NCBOESLPA, and should be mailed to:
NCBOESLPA
PO Box 16885
Greensboro, NC 27416

The form and check/money order MUST come together. If a check/money order comes in without a form, or vice versa, it will be returned to the sender.