Passport Sized Recent Head and Shoulder Photo 2 x 2 inches (51 x 51 mm)
Upload as JPEG

Board records, wall certificate and your seal will reflect first name, middle initial and last name unless another preference is indicated below.

Physical Residence Address

Email

The Board communicates with its licensees by e-mail to include renewal notices.
It is recommended that you provide the Board with two different e-mail addresses, particularly if you use an e-mail address with a .gov, .mil or .edu extension as those will often block e-mail from Constant Contact, which is the company the Board uses for mass e-mails.

Physical Business Address

Mailing Address

Background

1. Have you previously applied for certification or licensure as an EI or PE in North Carolina?
   Yes

   No
2. Have you previously applied for licensure in any other state and been denied?
   Yes

   No
   You must upload details in PDF format below.
3. Have you ever been disciplined on any professional license?
   Yes

   No
   You must upload details in PDF format below.
4. Have you ever been convicted of a felony?
   Yes

   No
   You must upload proof of restoration of civil rights in PDF format below.
5. Have you ever been convicted of a misdemeanor? (Do not include traffic violations.)
   Yes

   No
   You must upload details in PDF format below.
6. Are you a U.S. citizen?
   Yes

   No
   Provide detailed explanation of legal status in PDF format below.
7. Are you active duty military or a military veteran?
   Yes

   No
8. Are you an active duty military spouse?
   Yes

   No

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