Forms and Publications

Forms

Application Packages

Miscellaneous Forms for Licensees

Address and Email Change
Application to Supervise a Hearing Aide Dispenser Trainee
Application for Branch Office License NEW Apply Simply! Online Application! (Hearing Aid Dispensers and Dispensing Audiologists)
Application for multiple Branch Office Licenses (Hearing Aid Dispensers and Dispensing Audiologists)
Fieldwork Experience Verification Form
Fieldwork Experience Verification Form Undergraduate Clinical Experience
License Verification (HAD – DAU)
License Verification (AU - SLP – SPLA – AIDE)
Licensee Conviction and Discipline Reporting Form
Applicant Discipline Reporting Form
Name and Gender Change Notification and Request for Confidentiality (SB 372, 2023)
Name Change
Reactivating a License
Replacement License
RPE Extension Application
RPE Performance Review Form
RPE Change in Supervision or Work Plan
RPE Clinical Practicum/University Recommendation Form
RPE Verification Form
Subject Matter Expert Application for Enforcement Cases
SLP Assistant Supervisor Responsibility Statement
Termination of Supervision
Termination of Supervision for Hearing Aid Dispenser Trainee
Written Re-Examination Application Hearing Aid Dispensing

Downloadable License Application Packages

Speech-Language Pathologist License
Option #1 - Required Professional Experience: License Application Package for RPE Temporary License
Upon completion of 36 full-time weeks (or 72 part-time weeks) of required professional experience under an RPE Temporary License, applicant must submit the Permanent License Application, including the RPE Verification Form: License Application Package for Permanent Licensure as a Speech-Language Pathologist
Option #2 - Equivalent Qualifications: License Application Package for Equivalent Qualifications
Option #3 - Licensed in Another State: License Application Package for Current License in Another State
Option #4 - Previously Licensed in California: License Application Package for Previously Licensed
License Application Package for Foreign-Educated
Upon completion of all required weeks of required professional experience under an RPE Temporary License, applicant must submit the Permanent License Application, including the RPE Verification Form: License Application Package for Permanent Licensure as a Speech-Language Pathologist
Audiologist License
Option #1 - Required Professional Experience Temporary License for AU.D. students: License Application for Required Professional Experience Temporary License
Upon completion of 12 months of required professional experience under an RPE Temporary License, applicant must submit the Permanent License Application, including the RPE Verification Form: License Application Package for Permanent Licensure as an Audiologist
Option # 2 Equivalent Qualifications (Coming Soon)
Option #3 - License Application Package for Audiologist Licensed in Another State
Option #4 - Previously Licensed in California: License Application Package for Previously Licensed
Option 5# License Application Package for Foreign-Educated
Upon completion of 12 months of required professional experience under an RPE Temporary License, applicant must submit the Permanent License Application, including the RPE Verification Form: License Application Package for Permanent Licensure as an Audiologist
Speech-Language Pathology Assistant
Audiology Aide
Speech-Language Pathology Aide
Hearing Aid Dispenser
Option #1 - Application for Written Examination Only – No License Issued (No Dispensing Allowed)
Option #2 - Application for Hearing Aid Dispenser Trainee Temporary License with Supervision
Option #3 - Application for Hearing Aid Dispenser Temporary License – Licensed in Another State
Continuing Education Course Approval or Continuing Professional Development Provider Applications
Application for Hearing Aid Dispensing Course Approval (HA/DAU)
Application for Continuing Professional Development Provider License (SLP/AU)

Renewal Forms

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