Temporary Speech-Language Pathology Application

Section 1: General Information

Name*

Prefix First Middle Last

Maiden Name

If you have a maiden name that your paperwork is under please provide that name here. This allows us to process your paperwork faster.

Last

Preferred Mailing Address*

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

Home or Cell Phone*

Email*

Social Security Number*

Date of Birth*

Bilingual Language(s)

Add a row for each language

PRAXIS Examination Score if taken

Please make score available to reporting code 7757

Are you currently employed?*

Yes
No

Employer Information

Employer Name

Work Site Address

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

Business Phone

Military Status

NOTE: Pursuant to G.S. § 93B-15.1. (k) if you or your spouse hold active military status, you are not required to pay the application fee. Please provide us with any documentation validating their service. We will accept LES, Active Duty Orders, DD-214, etcetera. Photocopying of Military ID's is prohibited Title 18, U.S. Code, Part 1, Chapter 33, Section 701.

Military Status

Do you or your spouse hold active military status?

Yes
No

Who has military status?*

Me
My spouse

Supporting documents

Please submit official documentation confirming military status. If you do not have digital files to upload here, please include copies with your application when mailed.

Drop files here or

Max. file size: 50 MB.

Education

Education Information*

College or University	Major	Degree	Date

Attestation and Declarations

Employee Misclassification*

Required by N.C. Gen. Stat. § 143-764(a)(5), effective December 31, 2017 Any worker who is defined as an employee by N.C. Gen. Stat. §§ 95-25.2(4)(NC Department Of Labor), 143-762(a)(3)(Employee Fair Classification Act), 96- 1(b)(10)(Employment Security Act), 97-2(2)(Workers’ Compensation Act), or 105- 163.1(4)(Withholding; Estimated Income Tax for Individuals) shall be treated as an employee unless the individual is an independent contractor. Any employee who believes that the employee has been misclassified as an independent contractor by the employee’s employer may report the suspected misclassification to the Employee Classification Section within the North Carolina Industrial Commission. Employee Classification Section North Carolina Industrial Commission 1233 Mail Service Center Raleigh, NC 27699-1233 Telephone: (919) 807-2582 Fax: (919)715-0282 Email: emp.classification@ic.nc.gov

Employee misclassification is defined as avoiding tax liabilities and other obligations imposed by Chapter 95, 96, 97, 105, or 143 of the North Carolina General Statutes by misclassifying an employee as an independent contractor. (N.C. Gen. Stat. § 143-762(5))

I certify that I have read and understand the Public Notice Statement from the North Carolina Industrial Commission appearing above regarding the classification of employees.

Employee Misclassification*

I have been investigated for employee misclassification within the past three years

Yes
No

Employee Misclassification Results

Please upload the results of your employee misclassification investigation here.

Max. file size: 50 MB.

Article 22 Licensure Act for Speech and Language Pathologists and Audiologists*

I affirm that I have read and reviewed Article 22 Licensure Act for Speech and Language Pathologists and Audiologists including the Administrative Rules, Ethical Guidelines and Disciplinary Procedures and hereby agree to comply fully with them.

Yes
No

NC G.S. 90-301*

G.S. 90-301. Grounds for suspension or revocation of licenses.
Any person licensed under this Article may have his license revoked or suspended for a fixed period by the Board under the provisions of North Carolina General Statutes, Chapter 150B, for any of the following causes:
(1) His license has been secured by fraud or deceit practiced upon the Board.
(2) Fraud or deceit in connection with his services rendered as an audiologists or speech and language pathologist.
(3) Unethical or immoral conduct as defined in this Article or in a code of ethics adopted by the Board.
(4) Violation of any lawful order, rule or regulation rendered or adopted by the Board.
(5) Failure to exercise a reasonable degree of professional skill and care in the delivery of professional services.
(6) Any violation of the provisions of this Article.
(7) Failure to exercise good moral conduct as defined in rules adopted by the Board or in a code of moral conduct adopted by the Board. (1975, c. 773, s. 1; 1981, c. 572, s. 4; 1987, c. 665, s. 7; c. 827, s. 1; 2013-410, s. 47.7(f).)

I have read and understand that the Board uses my SSN for state reporting purposes. I have read and understand that by submitting this form, if I do not provide my assigned SSN I'm in violation of NC G.S. 90-301 (1), (3), (4), (6), and (7).

Praxis Score*

I understand that I must pass the Praxis Exam with a score of 162 or higher before my permanent license will be issued. This must be accomplished by the end of my SEY to maintain continuous licensure. Praxis exam scores should be made available to NCBOESLPA via ETS to reporting code 7757.

Yes
No

Official Transcripts*

I have sent a written request to my educational institution to have my transcripts sent directly to the Board office by either mail, or email transcripts@ncboeslpa.org.

Yes
No

Application Attestation*

The information that I have provided in this application is truthful. I understand that giving the Board false information of any kind may result in the voiding of this application and possible disciplinary action.

Yes
No

21 NCAC 64 .0104 Supplemental Information for Application*

21 NCAC 64 .0104 SUPPLEMENTAL INFORMATION FOR APPLICATION
The Board may require such supplemental information to the application as it deems necessary to determine the facts governing qualifications for licensure. The procedure for gathering such information may include subpoenas, depositions, affidavits, transcripts, audits, hearings and individual appearances before the Board.
History Note: Authority G.S. 90-304 (a)(1), (2), (3); Eff. February 9, 1976; Amended Eff. May 1,1989; Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. October 4, 2016.

I affirm and understand that, pursuant to Title 21, Chapter 64, Section .0104, the Board reserves the right to conduct searches of the National Practitioner Data Bank (NPDB) at its discretion. Such searches may be used to verify the information provided in my application and to determine the facts relevant to my qualifications for licensure, including but not limited to the disciplinary history of any license I currently hold or have previously held.

Permanent License Requirement*

I understand that in order to be issued my full, unrestricted, permanent license I will need to supply the Board with my passing ETS Praxis score. The reporting code is 7757

Yes
No

Disciplinary Action*

Has disciplinary action ever been taken against you by a licensing board or professional association?

Yes
No

Disciplinary Action: Explanation

Please include your explanation

Final Agency Decision and or Documentation

Please upload the licensing board or professional association decision here.

Drop files here or

Max. file size: 50 MB.

Conviction: Felony or Misdemeanor*

Have you ever been convicted of a felony or a misdemeanor?

Yes
No

Conviction: Felony or Misdemeanor Explanation

Please provide your date of conviction, where you were convicted, the charges, and other relevant information. If the conviction was set aside, give the date and provide detailed information. Be sure to attach the official court record (not a background check) when submitting your application.

Official Court Record

Be sure to attach the official court record (not a background check) when submitting your application.

Max. file size: 50 MB.

Notice of Proposed Rule Change – The Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC) view page

Step 1 of 14

APPLICATION FEE: $30.00
TEMPORARY LICENSE FEE (SEY): $40.00

Instructions

If you have questions about temporary licensure please refer to this list of our most common questions.

If you have general questions please refer to this list of our most common questions.

Section 1: General Information

Employer Information

Military Status

Education

Attestation and Declarations

Out-of-State Provisional License

Program Director's Recommendation

Signed Clinical Practicum Summary Sheet

Open Book Quiz: Article 22

Payment Information

Notice of Proposed Rule Change – The Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC) view page

Temporary Speech-Language Pathology Application

Step 1 of 14

APPLICATION FEE: $30.00 TEMPORARY LICENSE FEE (SEY): $40.00

Instructions

If you have questions about temporary licensure please refer to this list of our most common questions.

If you have general questions please refer to this list of our most common questions.

Section 1: General Information

Employer Information

Military Status

Education

Attestation and Declarations

Out-of-State Provisional License

Program Director's Recommendation

Signed Clinical Practicum Summary Sheet

Open Book Quiz: Article 22

Payment Information

APPLICATION FEE: $30.00
TEMPORARY LICENSE FEE (SEY): $40.00