License Renewal Application Form (License #: Od- ) - State Of Idaho printable pdf download

Owyhee Plaza

STATE OF IDAHO

(208) 334-3233

1109 Main St., Suite 220

BUREAU OF OCCUPATIONAL LICENSES

Boise Idaho 83702-5642

LICENSE RENEWAL APPLICATION

License #: OD-

Expiration Date: June 30 of each year

Renewal Fee: $150.00

The above noted renewal fee is for the next 12 month period and must be submitted to this office before the expiration date, also

noted above. License renewals submitted after the expiration date require a reinstatement fee of $150.00 in addition to the renewal

fee noted above.

Please submit this form with the required fee (check or money order) to the address noted above.

ALL RETURNED CHECKS ARE SUBJECT TO A $20.00 COLLECTION FEE.

PRINT NAME & ADDRESS BELOW AS IT

NOTE ADDRESS CHANGES BELOW:

APPEARS ON YOUR EXPIRING LICENSE

(Name changes must be accompanied by official

documents authorizing said change.)

______________________________

Please write your license number on your check or money order

DO NOT SEND CASH

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CONTINUING EDUCATION IN OPTOMETRY

EACH IDAHO LICENSED OPTOMETRIST SHALL ATTEND A MINIMUM OF 12 HOURS OF EITHER:

POST-GRADUATE OPTOMETRIC EDUCATION COURSES OR MEETINGS APPROVED IN ADVANCE BY THE BOARD, OR;

POST-GRADUATE STUDY SESSIONS OR SEMINARS AT AN ACCREDITED SCHOOL OR COLLEGE OF OPTOMETRY IN EACH 12 MONTH

PERIOD PRECEDING LICENSE RENEWAL. ALL COUNCIL ON OPTOMETRIC PRACTITIONERS EDUCATION (COPE) APPROVED COURSES

ARE APPROVED FOR CONTINUING EDUCATION CREDIT. IF YOU ATTEND OR PLAN TO ATTEND A COURSE OR SEMINAR WHICH HAS

NOT BEEN APPROVED IN ADVANCE, YOU MAY PETITION THE BOARD FOR APPROVAL OF THAT COURSE OF STUDY, AND PROVIDE A

DESCRIPTION OF THE COURSE.

NO MORE THAN 6 HOURS OF CORRESPONDENCE OR OTHER "HOME STUDY" CONTINUING EDUCATION SHALL BE PERMITTED EACH

YEAR.

THE BOARD MAY, UPON APPLICATION, WAIVE THE CONTINUING EDUCATION REQUIREMENTS IN CASES INVOLVING ILLNESS,

UNUSUAL CIRCUMSTANCES INTERFERING WITH AN OPTOMETRIST'S ABILITY TO PRACTICE, OR DUE TO ACTIVE MILITARY DUTY.

PLEASE LIST YOUR CE BELOW NOTING THE NAME OF THE COURSES, THE LOCATION, DATE AND HOURS OF ATTENDANCE AND

MAINTAIN THE REQUIRED DOCUMENTATION FOR 3 YEARS. THE BOARD MAY REQUIRE YOU TO SUBMIT DOCUMENTATION SHOWING

PROOF OF ATTENDANCE.

COURSE TITLE:

COURSE DATE(S):

SPONSORING ORGANIZATION & COURSE LOCATION:

TOTAL HOURS:

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TOTAL HOURS

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CONTINUING EDUCATION CERTIFICATE OF COMPLIANCE

I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT I HAVE COMPLETED THE CONTINUING EDUCATION OUTLINED ABOVE AS

REQUIRED BY THE IDAHO STATE BOARD OF OPTOMETRY LAWS AND RULES.

I FURTHER CERTIFY THAT I WILL PROVIDE PROOF

OF MY ATTENDANCE AT THE BOARD'S REQUEST.

SIGNATURE__________________________________________________

DATED THIS ____ DAY OF ________________, ______

License Renewal Application Form (License #: Od- ) - State Of Idaho

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