SPEECH-LANGUAGE PATHOLOGY          ASSISTANT LICENSE

Forms:

Checklist

Speech Assistant Application

Clinical Academic Requirement Form 

Letters of Agreement

First 90 Day Log

Monthly Supervision Request

SPEECH-LANGUAGE PATHOLOGY LICENSE

Forms:  

Checklist 

Licensure Application 

Required Reference Letter

CLINICAL FELLOW LICENSE 

Forms:

Checklist 

CF Application

Letters of Agreement

CF Plan

Academic Preparation and Practicum Verification Form

Required Reference Letter

AUDIOLOGY LICENSE 

Forms:

Checklist 

Licensure Application

Required Reference Letter

AUDIOLOGY ASSISTANT

AUTHORIZATION

Forms:

Checklist

Application 

Letters of Agreement 

OBESPA MAIL-IN

RENEWAL AND INACTIVE STATUS FORMS

 2022 Renewal Form

2022 Inactive Status Form

GENERAL FORMS

• Complaint Form
• Continuing Education Form and List of Approved CE Activities
• Reactivation Form
• Report of Clinical Fellowship
• Verification of Citizenship Affidavit
• Verifying Qualified Alien Status Affidavit