Application for National Board Certification

Congratulations on your decision to seek Board Certified in Hearing Instrument Sciences.

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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

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

Please attach notarized self-attestation form *

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Start date of dispensing experience*

Date

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

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: George Brown College/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. *

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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