Mailing List Request

Cost: $50 (+$3 for PayPal)
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 $3 fee will be added for online payments)
- 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.
Check/Money Order Payments*
Checks/money orders are made payable to NCBOESLPA, and should be mailed to NCBOESLPA, PO Box 16885, Greensboro, NC 27416. The form and payment must come together. If a payment comes without a form, or vice versa, it will be returned to sender.
- I understand!
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
Total
$0.00