Assistant Registration Renewal

RENEWAL FEE: $40.00
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.
Signed Name*
Assistant Information
Name*
Prefix First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Email

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Employer & Supervisor Information
Employer Name*
Primary Supervisor*
Prefix First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone*
Email*
Does the SLP-Assistant have an additional Primary Supervisor*
- Yes
- No
Primary Supervisor (Additional)*
Prefix First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone*
Email*
Does the SLP-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 SLP-A will provide services (except patient homes, just the general town/county is needed for specified home visits)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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 SLP-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.

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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.
Payment Information
Payment Options*
- PayPal (A $2 fee will be added for online payments)
- Mail Payment with printed form
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
SLP Assistant Registration Renewal Fee
The registration renewal fee is $40. If there are any changes in the primary or secondary supervisor for a SLP-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.

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Assistant Information