Application Form For Optometry License

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OPT
State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Board of Examiners in Optometry
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2580
E-mail: license@dced.state.ak.us
NONREFUNDABLE APPLICATION FEE:
$100.00
EXAMINATION FEE:
$210.00
INITIAL LICENSE FEE:
$290.00
WALL CERTIFICATE (OPTIONAL):
$ 20.00
APPLICATION FOR OPTOMETRY LICENSE
I HEREBY APPLY for a license to practice optometry in the State of Alaska, and submit the following statements, under
oath.
INSTRUCTIONS TO APPLICANT
All information requested in this application must be supplied by the applicant. Each question must be answered fully,
truthfully, and accurately. Any omissions, or inaccuracies are grounds for disapproval and rejection. If the space for any
answer is insufficient, the applicant may complete the answer on a rider signed by the applicant, specifying the number
of the question to which it related. Type or print all requested data.
1. Name in full
S.S. No.
(Required by AS 08.01.060)
2. Mailing address
City
State
ZIP Code
3. Daytime telephone
4. Date of birth
EDUCATION
5. High School
City and State
Date of Graduation
OR Date GED Awarded:
6. College or University
City and State
Years of attendance
Semester hours
Degree
7. School of optometry
City and State
Dates attended
Exact date of diploma
PERSONAL DATA • AS 08.72.240
ALL yes answers to the following questions must be explained in detail on a separate sheet of
Yes
No
paper. Please attach official documents as appropriate.
1. Have you ever practiced optometry in the State of Alaska?.....................................................
2. Have you ever been denied a license to practice optometry in any state? ..............................
3. Have you ever had your optometry license suspended, revoked, restricted, reprimanded, or
otherwise acted upon?..............................................................................................................
4. Have you ever been convicted of a felony or other crime? ......................................................
5. Within the past five years, have you been treated for/or hospitalized for emotional or mental
illness, drug addiction, or alcoholism? ......................................................................................
Please be aware that all information supplied with this application will be available to the public, unless required to be kept
confidential pursuant to state or federal law.
08-4232 (Rev. 1/00)

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