SLP-Assistant Registration

Cost: $40 (+$3 for PayPal)
THIS FORM MAY ONLY BE COMPLETED BY THE BOARD APPROVED SUPERVISING SLP. THIS FORM MAY NOT BE COMPLETED BY ANOTHER SLP, SLP-ASSISTANT, OR OFFICE STAFF.*
BY SIGNING I CERTIFY THAT I, THE POTENTIAL SUPERVISING SLP FOR THIS REGISTRANT IS COMPLETING THIS FORM AS REQUIRED BY ARTICLE 22.
Has the Assistant been registered with the NC Board of Examiners for Speech-Language Pathologists and Audiologists before?*
If the Assistant has not been registered with the NC Board they will need to fill out the Assistant Application.
- Yes
- No
NC Registration Number*
Date of Birth*
Supervisor Information
Primary Supervisor*
Prefix First Middle Last
NC License Number*
How many SLP-Assistants do you currently supervise?*
This should include all SLP-Assistant(s) that you supervise, including under other licenses/registrations you may hold in other jurisdictions. This also includes if you are the secondary supervisor for any SLP Assistant(s).
- None
- One
- Two or more
Primary Supervisor Email*
This email address will be used to send the primary supervisor instructions and a link to the required Performance-Based Competency Assessment & Orientation Checklist.
Do you have a secondary supervisor?*
- Yes
- No
Secondary Supervisor*
Prefix First Middle Last
How many SLP-Assistants does this licensee currently supervise?*
This should include all SLP-Assistants that they supervise, including under other licenses/registrations you may hold in other jurisdictions. This also includes if they are the secondary supervisor for any SLP Assistant(s).
- None
- One
- Two or more
NC License Number*
Assistant Information
Name*
Prefix First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone
Email
Employer Information
Employer Name*
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Service Locations*
Provide the exact location where the Assistant will provide services. Complete names and addresses are required for businesses, schools, Head Start Programs and daycares. If providing services in homes, please provide the city and/or county in which the homes are located.

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.
Academic Information
Academics*
Training Program Major Degree Date
SLP-Assistant Exam Date
Please select the date the exam was administered.
Month
Day
Year
SLP-Assistant Exam Score

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Supervisor & Assistant Consent & Signatures
Click here to download Section .1000-.1005 - Requirements for the Use of Speech-Language Pathology Assistants in Direct Service Delivery in North Carolina
To be completed by the Assistant
I have read Section .1000-.1005 – of Article 22 – Licensure Act for Speech-Language Pathologists - Requirements for the Use of Speech-Language Assistants in Direct Service Delivery in North Carolina and Audiologists, and I agree to abide by all of its requirements. I also certify that all information provided in this application is correct.
Signature of Assistant
Date
Month
Day
Year
To be completed by the Supervisor
As supervisor of the above listed applicant, I have read the Licensure Act for Speech-Language Pathologists and Audiologists including the Requirements for the Use of Assistants in Direct Service Delivery in North Carolina and I agree to abide by all of its requirements. I understand that as the supervisor, I accept responsibility for the professional services carried out by this Assistant. I also certify that all information in this application is correct.
Signature of Supervisor
Please print this file from the PDF that is emailed to you and have your supervisor sign here.
Notice
Any change in the above plan OR supervisor must be reported to the Board PRIOR to implementing the change or continuing the practice.
Upon Submission
Once the Board receives the completed paperwork and fee please allow up to 10 days for processing. To avoid processing delays, updates will not be provided in the duration of the 10 days. Once the request is approved you will receive and email confirming the change as well as your portal and the website will reflect the change.
Email (for PDF delivery)*
Please enter an email address to receive a copy of this completed form.
Payment Information
Payment Options*
- PayPal (A $3 fee will be added for online payments)
- Mail Payment with printed form
Registration Fee
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
Instructions: Mail in form with Payment
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.

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Guidance for OTC Hearing Aids View Resources

Step 1 of 3

Cost: $40 (+$3 for PayPal)

Supervisor Information

Assistant Information

Employer Information

Academic Information

Quiz

Assistant Protocol Target Behavior Form

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Supervisor

Notice

Upon Submission

Payment Information

Instructions: Mail in form with Payment

Related Documents

Why do Assistants have a Registration and not a License?

Training Program	Major	Degree	Date