Apprentice Registration Application

Use this form to apply for a new apprenticeship or to renew or replace an apprenticeship certificate previously issued.  The Plan of Supervision is included within this application.

Please review this page with your sponsor to ensure you have all necessary documentation ready prior to completing the electronic form.  The affidavit is the signature page for this application.  Both the sponsor and apprentice must sign an affidavit.  Carefully read the affidavit.  It requires that you affirm your review of North Carolina laws and regulations prior to submitting application.  You may print, sign, and notarize the affidavit before continuing so that it can be submitted electronically with the rest of the application. Use this link to review the state and federal laws and regulations:  http://nchalb.org/tab/ruleslist.php

 

SUMMARY OF APPLICATION QUESTIONS

Reason For Application
Choose initial certificate, change in sponsor, renewal, etc.

Applicant Info
Sponsor License Number
Sponsor Name

Applicant First Name
Applicant Middle Name
Applicant Last Name
Printed Name On Certificate
Applicant Email Address

Applicant Business Location
Applicant Mailing Address

Education Info
Select the highest level of education completed
Required: High School/GED information
Optional:  College

Audiometer Calibration Certificate
A calibration (current within past 12 months) for each audiometer used in business

Passport Photo Requirement
A digital photo may be submitted if it is a passport-style photo

Plan of Supervision
Review the following:
21 NCAC 22F .0301-.0306 Apprenticeship Rules
21 NCAC 22F .0105 Passing Examination
21 NCAC 22A .0401 Supervision definitions

Apprentice will work at least 27 hours/week for 50 weeks during one-year apprenticeship.
Provide good cause for renewal of apprenticeship if apprentice failed part of the exam.
Personal supervision is required until apprentice passes Parts A, B, and C of exam.

Notarized Affidavit
Affidavit must be signed by Sponsor and Applicant
A scanned copy submitted with electronic application is accepted as an original

Qualifications
1. Have you completed the required background check from Certifiedbackground.com using “NC16” as package code?
2. Are you now or have you ever been apprenticed and/or licensed to fit and dispense hearing aids in any other state?
3. Have you ever made an application for apprenticeship or for a license to fit/dispense hearing aids which was denied?
4. Have you ever taken and failed to pass an examination for issuance of a license to fit or dispense hearing aids in any other state?
5. Has your apprenticeship or license to fit or dispense hearing aids in any other state ever been revoked or suspended?
6. 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.
7. Have you ever been treated for alcoholism or narcotic abuse?
8. Have you ever filed for bankruptcy?
9. Have you ever been named as a party in a civil action (legal proceeding)?
10. 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?
11. 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)?
12. Will you be working under the supervision of a Registered Sponsor for less than 27 hours per week?

A detailed explanation is required for any “YES” response to Questions 2-12.
Response may be typed into application or attached as a separate document.

PLEASE NOTE:  Confidential information typed in this section will also be seen by the sponsor.  Submit confidential documentation directly to the Board.

Other Supporting Documents
You may email supporting documentation to app@nchalb.org.
Type “F1 Supplement, Apprentice Last Name” as the subject line.
You will also have an option to upload documents to your application.

PLEASE NOTE:  Any information not submitted electronically as part of application must be received by the Board within 10 business days -- see 21 NCAC 22A .0503(b).

Payment Options
Options include mailing payment, company making payment, or making an electronic payment.