21 NCAC 22A .0404         AFFIDAVITS

(a)  F1 Apprentice Registration Affidavit. An individual who seeks licensure from the Board and who is required to complete one full year of apprenticeship shall submit an F1 affidavit when submitting an apprentice registration electronic application. It requires the following:

(1)           the date of electronic application;

(2)           the sponsor first and last name, license number or registered sponsor certificate number;

(3)           the apprentice applicant first and last name, social security number, and date of birth of applicant;

(4)           attestation by the applicant and sponsor of the following: I hereby affirm that I have completed the Apprentice Registration Application ("Application"); that I have read and understand the complete Application; and that I declare under penalty of perjury, that all of the information, documents, and materials submitted in response thereto are true, correct, and complete. I understand that falsification or misrepresentation of any item or response in this duly-made application (see 21 NCAC 22A) shall constitute a sufficient basis for the Board to deny the Application, revoke my license or initiate and pursue any other disciplinary action including revoking my license after issuance. I attest that I have read and understand the rules promulgated by the NC State Hearing Aid Dealers and Fitters Board, codified as Title 21, Chapter 22 of the North Carolina Administrative Code and North Carolina General Statute Chapter 93D, and I agree to abide by the same;

(5)           applicant's and sponsor's signatures; and

(6)           notarization.

(b)  F4 Application for License and Exam Registration Affidavit. An apprentice or out of state applicant shall submit an F4 affidavit when submitting an application for licensure and exam registration. It requires the following:

(1)           the date of electronic application;

(2)           the first and last name, social security number, and date of birth of applicant;

(3)           attestation by the applicant of the following: I hereby affirm that I have completed the Application for License/Exam Registration ("Application"); that I have read and understand the complete Application; and that I declare under penalty of perjury, that all of the information, documents, and materials submitted in response thereto are true, correct, and complete. I understand that falsification or misrepresentation of any item or response in this duly-made application (as defined in 21 NCAC 22A) shall constitute a sufficient basis for the Board to deny the Application, revoke my license or initiate and pursue any other disciplinary action including revoking my license after issuance. I attest that I have read and understand the rules promulgated by the NC State Hearing Aid Dealers and Fitters Board, codified as Title 21, Chapter 22 of the North Carolina Administrative Code and North Carolina General Statute Chapter 93D, and I agree to abide by the same;

(4)           applicant's signature; and

(5)           notarization.

(b)  F6 Waiver of Apprenticeship Requirement Affidavit. An out of state applicant or military spouse applicant shall submit an F6 affidavit when submitting an application for licensure and exam registration. It requires the following:

(1)           the date of electronic application;

(2)           the first and last name of applicant;

(3)           attestation by the authorized board representative of the following: I hereby affirm that I am an authorized representative of the Board shown below; that I have reviewed the Board's official records regarding the above-named applicant; that applicant is currently licensed and has been continuously licensed in the state or jurisdiction of (insert jurisdiction) for the past three consecutive years immediately preceding this affidavit; and that a Verification of Licensure form (F7-VOL) has been completed to supplement this affidavit.; and

(4)           the date when giving attestation, first and last name of authorized board representative, title of representative, name of board, and board seal.

History Note:        Authority G.S. 93B‑14; 93B-15.1; 93D-3; 93D-5; 93D-8; 93D-9; 93D-13;

Eff. March 1, 2018.