Optometry Form 4 - Report Of Professional Practice - New York The State Education Department

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The University of the State of New York
Optometry Form 4
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
REPORT OF PROFESSIONAL PRACTICE
- FOR ENDORSEMENT APPLICANTS -
APPLICANT INSTRUCTIONS
Use this form only if you are licensed in another jurisdiction and are seeking licensure by endorsement.
1.
Complete all items in ink. In item 5, provide a chronological list of your professional practice with the name and practice address of the licensed
optometrist who will attest to your practice. Be sure to sign and date item 6.
2.
Complete Section I of a corresponding Form 4A and send it to each licensed optometrist listed in item 5.
Note: You must present evidence of at least five years of professional practice of optometry following initial licensure and within the 10 years immediately
preceding your application for licensure in New York.
Section I: Applicant Information
1
2
Birth Date
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Your Name Exactly As It Appears On Your Licensure Application (Form 1)
Last
First
Middle
Mailing Address
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
Professional Practice (Attach additional sheets if necessary)
5
Exact dates (mo./day/yr.)
Type of practice including name and practice address of licensed optometrist (attach additional sheets if necessary).
From _____ / _____ / _____
To
_____ / _____ / _____
From _____ / _____ / _____
To
_____ / _____ / _____
From _____ / _____ / _____
To
_____ / _____ / _____
I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I understand
6
that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure and may result in
criminal prosecution.
_____________________________________________________________________________________
_________________________
Applicant’s Signature
Date
Optometry Form 4, August 2005

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