Application for National Board Certification

Dear Applicant:

Congratulations on your decision to seek Board Certified in Hearing Instrument Sciences. In order to sit for the examination, you must complete in full this application. You will need the following documentation:

Your current state/provincial dispensing license or certificate of registration (where applicable). License or certificate must be current as of exam date.
The applicable fee (US FUNDS) -- payable online below.
A letter from employer/supervisor on company letterhead attesting to your two years dispensing experience (letter should include date) or diploma / certificate from: Bates Technical College/Hearing Instrument Technology, Burlington County College/Hearing Instrument Sciences, George Brown, Hearing Instrument Specialist, Conestoga College/Hearing Instrument Specialist, Grant MacEwan University/Hearing Aid Practitioner, Ozarks Technical Community College/Hearing Instrument Sciences, Douglas College/Hearing Instrument Practitioner, or Spokane Falls Community College/Hearing Instrument Specialist.
If you are self-employed or a business owner, please email NBC-HIS to discuss other options to verify dispensing experience.

Please take a picture or scan the above documents so that you are able to upload them as part of this online application.

Upon verification of eligibility, you will be contacted by the NBC-HIS office to schedule your exam. An exam confirmation notice will be emailed to you. Please take a copy of this confirmation with you to the exam site to facilitate the sign-in process.

After completing your exam you will receive your exam results immediately via email. If you are successful, you will be required to pay an annual revalidation/ recertification fee. The first fee will be due the calendar year following your certification date. The current annual fee is $275, but is subject to change.

Part I - Personal Information
Note: Enter your name exactly as you wish it to appear on your certificate should you earn a passing score.

Name*

PrefixFirst NameMiddle NameLast NameSuffix

Also known by or name used

First NameLast Name

Birthdate*

Date

Last four digits of your social security number*

Professional title / position

Example: Hearing Aid Specialist, Audiologist, Physician

Your Credentials

Contact Information

Email*

example@example.com

Check address you want used as your preferred mailing address*

Company AddressHome Address

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

Company Name

Franchise Name

Name of Manager/Supervisor

Name of Franchise Owner

Please take a moment and let us know how you found out about NBC-HIS.

I am a(n):

EmployeeBusiness / Franchise OwnerTrainer / Mentor

What prompted you to submit the NBC-HIS National Competency Exam Application?

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business Phone Number

Area CodePhone Number

Fax Number

Area CodePhone Number

If you have multiple business locations, please list their names, addresses, and phone numbers here

Part II - Professional Work/Experience

Note: List your professional/work experience for the past five (5) years, listing current employment first. Candidates MUST meet a minimum of two (2) years dispensing experience within the past five years.

Attach a letter from your employer verifying that you have two years or more of full-time dispensing experience. The letter should include dates. *

Browse Files

(Note: If self-employed or a business owner, call NBC-HIS for other options to verify dispensing experience).

Start Date:   Date
End Date:   Date or note "current" if still at this company
Work Experience Company Name:
Work Experience Company Address:   Street Address   Address Line 2   City   State   Zip
Name of Employer:   First Name   Last Name

Start Date:   Date
End Date:   Date
Work Experience Company Name:
Work Experience Company Address:   Street Address   Address Line 2   City   State   Zip
Name of Employer:   First Name   Last Name

Part III - Education, Training, Qualifications

High School:
Year of Graduation Name of High School
High School City High School State

Post Secondary School: (Post High School)
DO NOT LIST: Workshops, Seminars, Convention programs or Audited Courses.

Years Attended: Start Date Month/Year   End Date Month/Year
College/University: College/University   Street Address      City   State   Zip
Number of Years Completed:
Major:
Degree/Award:

Years Attended: Start Date Month/Year   End Date Month/Year
College/University: College/University   Street Address      City   State   Zip
Number of Years Completed:
Major:
Degree/Award:

Current Professional: Memberships, License, Registration(s)

Issue Date:   Month/Year
Name of Affiliated Body:
Membership/License/Registrations (s):

Issue Date:   Month/Year
Name of Affiliated Body:
Membership/License/Registrations (s):

Issue Date:   Month/Year
Name of Affiliated Body:
Membership/License/Registrations (s):

Issue Date:   Month/Year
Name of Affiliated Body:
Membership/License/Registrations (s):

Please list all states / provinces where you have a current license:

Attach your current state/provincial dispensing license, certificate of registration (where applicable), or diploma /certificate from: Bates Technical College/Hearing Instrument Technology, Burlington County College/Hearing Instrument Sciences, George Brown, Hearing Instrument Specialist, Conestoga College/Hearing Instrument Specialist, Grant MacEwan University/Hearing Aid Practitioner, Ozarks Technical Community College/Hearing Instrument Sciences, Spokane Falls Community College/Hearing Instrument Specialist. License or certificate must be current as of exam date. *

Browse Files

In compliance with the Americans with Disabilities Act and/or the Accessible Canada Act, please list any special requirements you may have:

Declaration
Please read before signing application

Information in this application, to the best of my knowledge, is true and correct.
No action is pending against me in any court or any other local, state or federal agency regulating my profession and/or business; or any state or national professional organization.
I have read and hereby pledge to abide by the NBC-HIS Code of Ethics.
I hereby give NBC-HIS authority to request necessary information from agencies, individuals, institutions and/or organizations named in this application and the attachments thereto in order to validate my application.
I hereby acknowledge that the Board Certified Certificate issued to me by NBC-HIS remains the property of NBC-HIS. At such time that I am no longer Board Certified by NBC-HIS, upon receiving a written request from NBC-HIS, I agree to return the certificate and all duplicate certificates which have been issued to me.

Signature*

Non-Discrimination Policy:

No applicant who has otherwise satisfied the application requirements shall be denied eligibility to the NCE because of age, sex, marital status, national origin, sexual preference, religious preference, race, or physical disability. Any individual who wishes to question any of the eligibility requirements of the National Board for Certification in Hearing Instrument Sciences (NBC-HIS) shall submit these concerns in writing to the NBC-HIS office.

Payment Information

All fees are in US currency and are NON-REFUNDABLE.*

Exam Fee$225.00

Enter coupon

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country