SPEECH-LANGUAGE PATHOLOGY          ASSISTANT LICENSURE

Forms:

Checklist for Speech Assistants 

Speech Assistant Application

Clinical Academic Requirement Form 

Letters of Agreement

First 90 day Supervision Log

SPEECH-LANGUAGE PATHOLOGY LICENSURE

Forms:  

Checklist 

Licensure Application 

CLINICAL FELLOW LICENSURE 

Forms:

Checklist 

CF Application

Letters of Agreement

CF Plan

          AUDIOLOGY LICENSURE 

Forms:

Checklist 

Licensure Application

AUDIOLOGY ASSISTANT AUTHORIZATION

Forms:

Checklist

Application 

Letters of Agreement 

OBESPA Mail-In 

Renewal and Deactivation Forms

Select the form below to print your 

2018 Renewal Form

2018 Deactivation Form

GENERAL FORMS

• Academic Preparation and Practicum Verification Form SLP
• Non-Accredited Degree Program Practicum Form
• Non-Accredited Degree Program Preparation Form
• Report of Clinical Fellowship
• Verification of Citizenship Affidavit
• Verifying Qualified Alien Status Affidavit
• Reactivation Form
• Required Reference Letter (need three)
• Trak 1 Background Search 
• Complaint Form
• Continuing Education Form and List of Approved CE Activities
• SLPA weekly Supervision Log