21 NCAC 22A .0403 FORMS

(a) F1 Form Apprentice Registration Application. An individual who seeks licensure from the Board and who is required to complete one full year of apprenticeship shall submit a F1 form when submitting an apprentice registration electronic application for a new apprenticeship or to renew or replace an apprenticeship certificate. It requires the following:

(1) the sponsor last name;

(2) the reason for application by applicant;

(3) the sponsor license number and first and last name;

(4) the applicant first and last name, email address, and name to be printed on certificate;

(5) the apprentice business location, including business name, address, city, state zip code, county, and phone number;

(6) the apprentice mailing address;

(7) the education information including high school/GED school name, city, county, state, and year completed;

(8) acknowledgement of audiometer calibration certificate;

(9) acknowledgement of passport photo requirement;

(10) answering questions regarding the plan of supervision;

(11) acknowledgement of F1 Affidavit;

(12) acknowledgement of background check;

(13) answering the following yes or no questions:

(A) are you now or have you ever been apprenticed or licensed to fit and dispense hearing aids in any other state;

(B) have you ever made an application for apprenticeship or for a license to fit and dispense hearing aids that was denied;

(C) have you ever taken and failed to pass an examination for issuance of a license to fit and dispense hearing aids in any other state;

(D) has your apprenticeship or license to fit and dispense hearing aids in any other state ever been revoked or suspended;

(E) have you ever been convicted of or forfeited bond in connection with a criminal offense (i.e. misdemeanor or a felony)? Include DUIs and DWIs;

(F) have you ever been treated for alcoholism or narcotic abuse;

(G) have you ever filed for bankruptcy;

(H) have you ever been named as a party in a civil action (legal proceeding);

(I) to your knowledge, has a complaint ever been filed against you (or a company owned by you) with a hearing aid related board or organization, the Federal Trade Commission, or any consumer protection agency;

(J) to your knowledge, is there anything that would impair your ability to perform the functions for which you are licensed (such as a physical or mental disability);

(K) will you be working under the supervision of a Registered Sponsor for less than 27 hours per week; and

(14) selection of payment options.

(b) F4 Form Application for License and Exam Registration. An apprentice or out of state applicant shall submit a F4 form when submitting an application for licensure and exam registration. It requires the following:

(1) the email address, first, and last name of applicant;

(2) the reason for application by applicant;

(3) the name as applicant wishes to have it printed on license;

(4) selection of exam part, exam period, and exam time preference;

(5) acknowledgement of exam reminders;

(6) acknowledgement of additional required documents;

(7) selection of payment options;

(8) the education information including high school/GED school name, city, county, state, and year completed;

(9) acknowledgement of background check;

(10) answering the following yes or no questions:

(A) are you now or have you ever been apprenticed or licensed to fit and dispense hearing aids in any other state;

(B) have you ever made an application for apprenticeship or for a license to fit and dispense hearing aids that was denied;

(C) have you ever taken and failed to pass an examination for issuance of a license to fit and dispense hearing aids in any other state;

(D) has your apprenticeship or license to fit and dispense hearing aids in any other state ever been revoked or suspended;

(E) have you ever been convicted of or forfeited bond in connection with a criminal offense (i.e. misdemeanor or a felony)? include DUIs and DWIs;

(F) have you ever been treated for alcoholism or narcotic abuse;

(G) have you ever filed for bankruptcy;

(H) have you ever been named as a party in a civil action (legal proceeding);

(I) to your knowledge, is there anything that would impair your ability to perform the functions for which you are licensed (such as a physical or mental disability);

(J) will you be engaged in fitting and selling hearing aids for less than 27 clock hours per week;

(11) the business address information of applicant; and

(12) attestation of duly made application.

(c) F7 Form Verification of License. An out of state or military spouse applicant shall submit a F7 verification of license form when submitting an application for licensure and exam registration. It requires the following:

(1) authorization from the applicant for a state board, other than N.C., having control of any documents, records and other information pertaining to the applicant to furnish to the Board information, including documents, records regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent information;

(2) license verification by providing: the applicant first and last name, the board and State, the licensure status, the license number, the issue and expiration date of license;

(3) education verification if applicant has an audiology degree on file;

(4) discipline information by answering the following yes or no questions:

(A) has the applicant ever been the subject of complaints or charges received by your board;

(B) has the applicant ever been warned, censured or disciplined in any manner by your board;

(C) has any application by the above applicant for initial licensure or reinstatement ever been denied; and

(5) board seal, signature and title of person filling out information, and date.

(d) F10 Form - Application for License and Exam Registration for Military-Trained applicant or Military Spouse applicant. An applicant for apprentice registration shall submit a F10 form when submitting an application for licensure and exam registration. It requires the following:

(1) indication of whether the applicant is new or returning;

(2) the applicant first and last name, and email address;

(3) the applicant business location, including business name, address, city, state zip code, county, and phone number;

(4) the applicant mailing address;

(5) the reason for application;

(6) selection of exam part, exam period, and exam time preference;

(7) selection of option to mail or electronically submit required documentation;

(8) the education information including high school/GED school name, city, county, state, and year completed;

(9) the military program of training (if applying as military-trained applicant);

(10) the experience in fitting and selling hearing aids;

(11) acknowledgement of background check; and

(12) answering the following yes or no questions:

(A) are you now or have you ever been apprenticed or licensed to fit and dispense hearing aids in any other state;

(B) have you ever made an application for apprenticeship or for a license to fit and dispense hearing aids that was denied;

(C) have you ever taken and failed to pass an examination for issuance of a license to fit and dispense hearing aids in any other state;

(D) has your apprenticeship or license to fit and dispense hearing aids in any other state ever been revoked or suspended;

(E) have you ever been convicted of or forfeited bond in connection with a criminal offense (i.e. misdemeanor or a felony)? Include DUIs and DWIs;

(F) have you ever been treated for alcoholism or narcotic abuse;

(G) have you ever filed for bankruptcy;

(H) have you ever been named as a party in a civil action (legal proceeding);

(I) to your knowledge, has a complaint ever been filed against you (or a company owned by you) with a hearing aid related board or organization, the Federal Trade Commission, or any consumer protection agency;

(J) to your knowledge, is there anything that would impair your ability to perform the functions for which you are licensed (such as a physical or mental disability); and

(K) will you be working under the supervision of a registered sponsor for less than 27 hours per week?

 

History Note: Authority G.S. 93B-8.1; 93B-15.1; 93D‑3; 93D-5; 93D-6; 93D-8; 93D-9; 93D-11; 93D-13;

Eff. March 1, 2018.