Application Payment - Information

All sections of the form are mandatory and must be completed. If you have any questions you may contact the board office at (775) 787-3421.


Standard Application Fee: $250.00 $125.00 Military Fee	Provisional License Fee: $250.00 $125.00 Military Fee
Temporary License Fee: $200.00 $100.00 Military Fee	Standard Audiologist Application with Dispensing Endorsement Fee: $300.00 $175.00 Military Fee

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Personal Information

Please complete the information below.


First Name	Middle Name	Last Name	Suffix
Mailing Address	City	State	ZIP Code
Contact Phone Number	Alternate Phone Number	E-Mail Address

Application Fee

Please select the application fee you are paying.

Declaration


	I declare, under penalty of perjury, all the information supplied herein is to the best of my knowledge true, accurate and complete.


Standard License
Provisional License
Temporary License
Standard Audiologist Application with Dispensing Endorsement
Military Service or Veteran Status	Yes	No