Ophthalmic Dispensing Form 3 - Certification Of Ophthalmic Dispensing License In Another Jurisdiction - New York The State Education Department
ADVERTISEMENT
1
2Ophthalmic Dispensing
The University of the State of New York
Form 3
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF OPHTHALMIC DISPENSING LICENSURE
IN ANOTHER JURISDICTION
APPLICANT INSTRUCTIONS
1.
Complete Section I in ink. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 8.
2.
Send this form to the licensing authority in the state where you were licensed to practice as an ophthalmic dispenser. Be sure to include any
fee required by that jurisdiction.
Note: A separate Form 4 must be received by the Department from every jurisdiction in which you are or have been licensed.
SECTION I: APPLICANT INFORMATION
1
2
Social Security Number
Birth Date
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
5
Telephone/E-Mail Address
Middle
Daytime Phone
4
Mailing Address
(
You must notify the Department promptly of any address or name changes.)
Line 1
Area Code
Phone Number
Line 2
E-Mail Address (Please print clearly)
Line 3
City
State
Zip Code
Country/
Province
6
If you took a licensing examination in the United states using a different name, enter that name below:
_________________________________________________________________________________________________________________
Last
First
Middle
7
If licensed in the United States to dispense eyeglasses and or contact lenses, give state: __________________________________________
Date license was issued: _______ / _______ / _______
License number: ________________________________
mo.
day
yr.
Are you authorized to dispense eyeglasses in this jurisdiction?
Yes
No
Are you authorized to dispense/fit contact lenses in this jurisdiction?
Yes
No
8
I request and give my permission to the licensing authority to complete Sections II and III of this form, release any other information required by
the State Education Department in connection with my application for licensure, and return this form directly to the State Education Department
at the address at the end of this form.
_____________________________________________________________________________________
_________________________
Signature
Date
Ophthalmic Dispensing Form 3, Page 1 of 2, Rev. 12/04
ADVERTISEMENT
0 votes
Related Articles
Related forms
Optometry Form 3 - Verification Of Licensure/certification In Another Jurisdiction - New York The State Education Department
Legal
Midwifery Form 2a - Certification Of Pharmacology Course Or The Equivalent Of Not Less Than Three Semester Hours - New York The State Education Department
Legal
Ophthalmic Dispensing Form 4 - Certification Of Trainee Experience In Ophthalmic Dispensing And/or Contact Lens Dispensing - New York The State Education Department
Legal
Ophthalmic Dispensing Form 5 - Application For Limited Permit - New York The State Education Department
Legal
Licensed Master/social Worker - Application For Licensure - The University Of The State Of New York The State Education Department - 2016
Legal
Form Preschool Stac-1 - Request For Commissioner's Approval Of Reimbursement For Services For Students With Disabilities - The University Of The State Of New York, The State Education Department
Business
Massage Therapy Form 3 - Verification Of Out-of-state Licensure Or Registration - New York The State Education Department
Legal
Cytotechnologist/certified Histological Technician - Certification Of Professional Education - The University Of The State Of New York The State Education Department - 2008
Legal
Related Categories
Parent category: Legal