Application Form For Optometry License (Page 2 of 2) in pdf

Application Form For Optometry License Page 2

PROFESSIONAL STATUS (List memberships in good standing of Optometric Societies.) Name/Location

OCCUPATIONAL STATUS (Past five years only.)

Position

Location

Date of Employment

LIST ALL JURISDICTIONS IN WHICH YOU HOLD OR HAVE HELD LICENSES TO PRACTICE OPTOMETRY

State Board

Certification Number

Date of Issue

Current Status

Exam or Reciprocity

CHARACTER AND PROFESSIONAL REFERENCES (Indicate three)

NAME

ADDRESS

CONTACT TELEPHONE

Two reference letters (attached form 08-4232a) must be completed by two persons who have knowledge of your character and

professional abilities.

I CERTIFY UNDER PENALTY OF UNSWORN FALSIFICATION PURSUANT TO AS 11.56.210 THAT THE

STATEMENTS IN THIS APPLICATION ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Signature

ATTACH RECENT PHOTOGRAPH

(Taken within the last six months)

Date

No larger than 3 x 3

NOTICE:

Portion of the Notary Seal must overlie the

photograph

SUBSCRIBED AND SWORN to before me this

day of

NOTARY SEAL

Notary Public

My Commission Expires:

08-4232 (Rev. 1/00)

Application Form For Optometry License Page 2