Verifications to Professional Entities

Cost: $15.00 (+$3 for PayPal)
Licensee/Assistant Information
Licensee/Assistant Name*
Prefix First Middle Last
Licensee/Assistant Email*
What type of license/registration do you hold with the NC Board?*
- Full, unrestricted, permanent license
- Temporary
- Expired
- None I am an Assistant
License Number (Permanent)*
License Number (Temporary)*
Assistant Registration Number*
Have you held more than one license with the NC Board?*
If so, please provide the other license numbers.
- Yes
- No
Additional Licenses with the NC Board*
Please list those other numbers below. If you’re unsure of the number(s) you can call the Board office at 336-272-1828.
Licensee/Registrant Previous Name(s)
If you held a previous license or registration with the Board and it was under a different name please enter the name(s) used below.
Form Upload
Please upload the verification form from the state you are applying if that state requires a certain form. If a form is not uploaded with this request, a standard verification will be sent.
Accepted file types: jpg, pdf, Max. file size: 50 MB.
Verification Information Recipient
Name/Organization to Send Verification To*
Email
If you would like your verification emailed directly to the recipient please put their email address here.
Address*
The address provided should belong to the Name/Organization listed above.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email (for PDF delivery)*
Please enter an email address to receive a copy of this completed form.
Payment Information
Verification*
Payment Options
- Mail Payment with printed form
- PayPal (A $3 fee will be added for online payments)
Mail payment with printed form*
I understand that if I choose to mail in payment with printed form the Board office will not receive my form submission. I understand that the most common reason for delay is error in completing the form correctly, providing the required information, and not following the instructions. Error can be avoided if you proceed through this form submission carefully, thoroughly, and accurately. If you have any questions or need assistance, call the Board of Examiners at 336-272-1828.
I understand
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
Total
$0.00

Save and Continue Later

Guidance for Audiometric Screenings as Part of Speech-Language Evaluations

Cost: $15.00 (+$3 for PayPal)

Licensee/Assistant Information

Verification Information Recipient

Payment Information

Assistants