Retired Volunteer License Form

Complete the form below to submit a request to convert a full license to a retired limited volunteer license. You will receive an email confirming receipt of your request.

Conversion of Full License to Retired Volunteer License

By submission of this form I indicate my wish to convert my full North Carolina professional license to a Retired Limited Volunteer License. I understand that I may not receive or accept any compensation or payment, direct, monetary, in-kind, or otherwise, for the provision of medical services rendered as a volunteer. I understand I must continue to comply with applicable continuing medical education requirements. 

I propose to practice in the following location(s):
Applicant Information