Form Dop - Apprentice Registration - Alaska Department Of Community And Economic Development Page 5
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6STATE OF ALASKA
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
VERIFICATION OF WORK EXPERIENCE
Applicant is to complete the top section. It is to be mailed to your former employer if you are attempting to obtain Alaska
licensure by credentials or if you wish to receive credit toward apprenticeship. Your employer must verify 6,000 hours or 3 years
of full-time work as a dispensing optician.
Applicant Signature:
Printed Name:
Former Name:
Address:
Mailing Address:
Social Security Number:
PLEASE DO NOT DETACH.
The information below must be completed by a former employer and returned to the address
above, Alaska State Board of Dispensing Opticians.
Employee Name:
Last
First
MI
Maiden
Business Name:
Mailing Address:
City
State
ZIP Code
Telephone Number:
Dates of Employment: From
to
Total Hours:
Average number of hours worked per week:
Job Title:
q
q
Categories:
Spectacles
Contact Lenses
Name of licensed individual supervising, if applicable:
License Type:
State of Licensure:
License No.
q
q
American Board of Opticianry Certified?
Yes
No
Other comments:
I hereby certify that the above information is true and correct to the best of my knowledge.
Signature:
Title:
Printed Name:
Date:
SUBSCRIBED AND SWORN before me, a Notary Public, in and for the state of
this
_______ day of
, 20______
SEAL
Notary Public
My Commission Expires:
08-4002c (Rev. 7/00)
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