BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD
2005 Evergreen Street, Suite 2100, Sacramento, CA 95815
P 916-263-2666
F 916
-263-0505 TDD 916-322-1700 www.speechandhearing.ca.gov/
REQUEST FOR REPLACEMENT LICENSE
This completed form must be submitted along with a check or money order made payable to SLPAHADB. The fee is
$25.00 per document. All documents will be mailed to the address of record. Please allow 3-4 weeks for processing.
When requesting replacements due to name and/or address change, the documents being replaced must be returned
with this form.
Please Note: All licensees are permitted one wall license and one pocket license. Duplicates are not provided for any
reason including license verification and/or multiple locations.
Please print or type:
NAME: ________________________________________________________________________________________
LICENSE TYPE:
(Check one) SP AU DAU SPA HA RPE
LICENSE NUMBER: _________________ CONTACT PHONE #: ________________________________________
(
Please include area code).
ADDRESS OF RECORD: _________________________________________________________________________
(Street)
Would you like your address
of record changed?
__________________________________________________________________________
(City, State, Zip Code)
YES NO
SELECT THE LICENSE YOU ARE REQUESTING: ($25.00 fee per document)
Original Wall License Renewal Wall License Pocket License
REASON FOR REQUEST:
Lost Stolen Original Not Received
Address Change Name Change
(Please be sure to complete the Notification of Name Change and send supporting documentation).
.
I certify under penalty of perjury of the laws of the State of California that I am the person who was issued the original
wall and/or pocket certificates by the Speech-Language Pathology & Audiology & Hearing Aid Dispensers Board, for
which I am requesting replacements. I declare under penalty of perjury under the laws of the State of California that the
foregoing is true and correct.
SIGNATURE: ______________________________________________________________ DATE: _____________________
INFORMATION COLLECTION AND ACCESS
The Speech-Language Pathology & Audiology & Hearing Aid Dispensers Board’s Executive Officer is the person who is responsible for information maintenance. Section
2532 of the Business and Professions Code is the authority, which authorizes the maintenance of the information. All information is mandatory. Failure to provide any
mandatory information will result in the application being rejected as incomplete. The information provided will be used to determine qualification for licensure. Each
individual has the right to review his or her file maintained by the agency subject to the provisions of the California Public Records Act.
(REV. 12/11)
