SLP-Assistant Registration Renewal

Cost: $40.00 (+$3 for PayPal)

This form may only be completed by the Board approved supervising licensee. This form may not be completed by another Licensee, Assistant, or Office Staff.*

By Signing I Certify that I, the supervising licensee for this registrant is completing this form as required by Article 22.

Signed Name*

Assistant Information

Name*

Prefix First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Email*

Employer & Supervisor Information

Employer Name*

Primary Supervisor*

Prefix First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Work Phone*

Email*

Does the Assistant have an additional Primary Supervisor*

Yes

No

Primary Supervisor (Additional)*

Prefix First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Work Phone

Email

Does the Assistant have a secondary supervisor?*

Yes

No

Secondary Supervisor*

Prefix First Middle Last

Services Location

Provide the exact location and name of all locations that the Assistant will provide services (except patient homes, just the general town/county is needed for specified home visits)

Street Address Address Line 2 City State ZIP Code

Are there multiple locations where services will be provided?*

Yes

No

Additional Locations*

Please list any additional locations where services will be provided. We must have address locations for each location the Assistant is providing services (DO NOT JUST LIST DAYCARES WITHOUT GIVING THE NAME AND ADDRESS). With the exception being home locations, we just need the general town/city area the home service is provided.

Signature of Primary Supervisor*

Please use your mouse (desktop) or your finger/stylus (mobile/tablet) to sign this form.

Email (for PDF delivery)*

Please enter an email address to receive a copy of this completed form. Please note that the Board is no longer sending out Assistant Registration Certificates. The certificates are now available through the Primary Supervisors Portal once the registration is completed

Payment Information

Payment Options*

PayPal (A $3 fee will be added for online payments)

Mail Payment with printed form

Total

Payment Method*

American Express

Discover

MasterCard

Visa

Maestro

Card Number Expiration Date Security Code Cardholder Name

SLP Assistant Registration Renewal Fee

The registration renewal fee is $40. If there are any changes in the primary or secondary supervisor for an Assistant, a new supervision change form is required. If a supervision change is made after this renewal is paid and before the next renewal is due, the fee to make the change is $20.

Upon submission of this form, an email will be sent to the address provided above. The email will contain an attached PDF and a link to a PDF of the form you completed. Please print your form and return with payment.

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.

OTC Hearing Aids and "Prescription" Hearing Aids Resource Page view page

Assistant Renewal Online Form

Cost: $40.00 (+$3 for PayPal)

Assistant Information

Employer & Supervisor Information

Payment Information