Fillable NCBLCMHC Payment Form (North Carolina Board of Licensed Clinical Mental Health Counselors)

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NCBLCMHC Payment Form (North Carolina Board of Licensed Clinical Mental Health Counselors)

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The NCBLCMHC Payment Form (North Carolina Board of Licensed Clinical Mental Health Counselors) form is 3 pages long and contains:

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  • 12 check-boxes
  • 42 other fields

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File type: PDF

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NCBLCMHC Payment Form
Name of Applicant/Licensee: ____________________________________
Telephone: Day:_________________________ Evening: _____________________________
Alternate Address for mailing (if requesting information be sent to other agencies or boards):
Please check what you wish to pay for:
Licensing Fees: LCMHC Associate LCMHC
LCMHC Supervisor
Application $200.00
License Renewal $200.00
Late License Renewal $275.00
Fingerprint Fee $38.00
Professional Corporation Fees:
Professional Corporation Application $50.00
Professional Corporation Renewal $25.00
Professional Corporation Renewal $35.00
Name of PC: ___________________________________________________ PC # _________________
Miscellaneous:
Copy of Licensure File = $____________
Duplicate License = $____________
Mailing List (Educational Purposes Only)
$50.00 x ________
$15.00 x ________
$10.00 x ________
= $____________
(contains work addresses only)
= $____________
Summation of Supervised Professional Practice $25.00 x ______
Verification of Licensure
$ 5.00 x _______
= $____________
1. 2.
Page 1 of 3
FOR OFFICE USE ONLY
REF. #:__________________________
BATCH #: _______________________
DATE: __________________________
CHECK #: _______________________
AMOUNT: _______________________
This page intentionally left blank
NCBLCMHC Payment Form
(continued)
Enclosed is a check or money order (payable to NCBLCMHC) in the amount of $
I authorize NCBLCMHC to charge my credit card as listed below in the amount of $
Cardholder name as it appears on the card:
Credit Card #:
Card Security Code (from back of card):_____________________ Exp. Date:
If payment for someone other than Applicant/Licensee:
Billing Address: ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Telephone: Day: _________________________ Evening: _____________________________
Signature of Cardholder: ____________________________________________________________
Page 3 of 3
(mm) (yy)
If paying by check, please make check payable to NCBLCMHC. Mail completed form and payment to
NCBLCMHC, PO Box 77819, Greensboro, NC 27417. If paying via credit card, the form can be faxed to
336.217.9450.
.
.
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NCBLCMHC Payment Form (North Carolina Board of Licensed Clinical Mental Health Counselors)

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Completed 4 September 2021

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