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Form Dop - Apprentice Registration - Alaska Department Of Community And Economic Development

DOP

STATE OF ALASKA

FOR OFFICE USE ONLY

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

ALASKA STATE BOARD OF DISPENSING OPTICIANS

P.O. BOX 110806

JUNEAU, ALASKA 99811-0806

(907) 465-5470

E-mail: license@dced.state.ak.us

APPRENTICE REGISTRATION

(To be completed by Apprentice)

$50.00 Application Fee

Spectacles and Contacts

Make check or money order payable to the State of Alaska.

New Registration

Continued Registration with New Sponsor

Full Name of Apprentice:

Last

First

Middle

Other Name (Name(s) under which previously known):

Mailing Address:

Street Address or P.O. Box

City

State

Zip Code

Telephone Number: Day:

Evening:

Social Security Number:

Date of Birth:

Name and Address of Business Where Training will be Received:

Physical Address

City

State

Zip Code

Supervisor Name:

Alaska License Number:

List previous training (only out-of-state training submitted at time of initial registration or apprenticeship registered training in

Alaska is acceptable, and must be verified by completion of attached forms).

Name of Optical Company

Hours Earned

Exact Dates of Training

I understand that once the board approves my apprenticeship, I and my supervisor will receive a written registration/authori-zation

indicating date of registration. It is my responsibility to obtain verification of training when my training under this supervisor ends.

Signature of Applicant

SUBSCRIBED AND SWORN before me, a Notary Public, in and for the state of

this

day of

SEAL

Notary Public

08-4002 (Rev. 7/00)

My Commission Expires:

Form Dop - Apprentice Registration - Alaska Department Of Community And Economic Development

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