Form Dop - Application For Dispensing Optician License By Examination Or By Credentials - Alaska Department Of Community And Economic Development Page 3

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You may photocopy this document if you are licensed in more than one state.
STATE 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 LICENSURE AND EXAMINATION
PART I (Print)
APPLICANT: Complete Part I. Mail to the state in which you obtained licensure for completion of Part II.
Name:
Last
First
MI
Maiden
Address:
Street
City
State
ZIP Code
Social Security Number:
PART II
The above applicant is applying for licensure in this state. Please complete the following and return directly to the Alaska State Board.
State:
Licensee's Name:
License No.:
Issue Date:
Expiration Date:
License Type:
Spectacles
Contact Lenses
Method of Licensure:
Exam
Endorsement
Waiver
SPECTACLES EXAMINATION:
National Written:
Year taken
State Written:
Year taken
Hours long
Content of exam
Practical:
Year taken
Hours long
Content of exam
CONTACT LENSES EXAMINATION:
National Written:
Year taken
State Written:
Year taken
Hours long
Content of exam
Practical:
Year taken
Hours long
Content of exam
Pending disciplinary action or pending investigation against this license?
Yes
No
If yes, explain on reverse side of this form.
Former disciplinary action: Has this license ever been ENCUMBERED in any way?
Yes
No
If yes, dates
Explain
Signature
Title
State Board
Date
BOARD SEAL
08-4151a (Rev. 8/00)

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