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Wall Certificate Order Form
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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
*
Credit Card
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.
Licensees
Account Activation Tutorial
Expired License
Renew my License
Delinquent Fee
Continuing Education
Employee Misclassification
Temporary Licensee
Verifications to other states
Mailing List Request
Request for Board Certificate to Incorporate
Wall Certificate Order Form
©2022 North Carolina Board of Examiners for Speech-Language Pathologists and Audiologists
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COVID-19
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