Verifications to other states

Cost: $15.00 (+$2 for PayPal)
Licensee Information
Licensee Name*
Prefix First Middle Last
Licensee Email*
What type of license do you hold with the NC Board?*
- Full, unrestricted, permanent license
- Temporary
- Expired
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.
License Number (Permanent)*
License Number (Temporary)*
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 $2 fee will be added for online payments)
Mail Payment with printed form instructions:
- Print off PDF form submission sent to the email address provided in, "Email (for PDF delivery)".
- Include any additional documentation needed.
- Include a check or money order. These are made payable to NCBOESLPA.
- Mail everything to:
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.

If there are additional requirements needed for this verification that are not covered in this form please contact Sergei Maxfield.
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

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Audiology & Speech-Language Pathology Interstate Compact Information Page

Cost: $15.00 (+$2 for PayPal)

Licensee Information

Verification Information Recipient

Payment Information

Mail Payment with printed form instructions: