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

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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.

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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 $3 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 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.

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Assistant Information