Application for National Board Certification

Dear Applicant:

Congratulations on your decision to seek Board Certification in Hearing Instrument Sciences (BC-HIS). 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) -- NBC-HIS will contact you to collect payment.
Self-Attestation form (please note: this will need to be notarized

Please note: the above documentation is required. Your application cannot be submitted without uploading required documentation and payment.

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 exam completion, results will be sent 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 $299 (US/International) or $215 (Canada), but is subject to change.

If you would like an application to print and fill out manually, please email info@nbc-his.com

You cannot complete your application without a notarized copy of your self-attestation form.

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 notarized self-attestation form*

Browse Files

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: MacEwan University Hearing Aid Practitioner Program, George Brown Hearing Instrument Specialist Program, Conestoga College Hearing Instrument Specialist Program, Douglas College Hearing Aid Services, or Spokane Falls Community College Hearing Instrument Specialist Program. License or certificate must be current as of exam date. *

Browse Files

In compliance with the Americans with Disabilities 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 / certificant shall be denied certification or recertification based on sex, marital status, age, religious preference, nationality, sexual orientation, race, or disability except when that disability affects the ability of the applicant to provide professional-level service to their patients/clients.