Form Dop - Application For Dispensing Optician License By Examination Or By Credentials - Alaska Department Of Community And Economic Development Page 6
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8STATE 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 APPRENTICE TRAINING
This form must be returned to the Board of Dispensing Opticians at the above address.
This form must be completed and signed by the licensed physician, optometrist, or dispensing optician who directly supervised
the hours obtained in dispensing optician duties. (NOTE: "direct" supervision means that the licensed supervisor is physically
present at the same site while dispensing optician tasks are being performed by the apprentice under the supervision of the
supervisor.)
Name of Apprentice:
Social Security Number:
Name of business where training was received:
Mailing Address:
City
State
ZIP Code
Telephone Number:
Supervisor Name:
License Type:
State of Licensure:
License No.
American Board of Opticianry Certified?
Yes
No
Dates of Employment: From
to
Total Hours:
Type of Training:
Spectacles
Contact Lenses
Hours per week:
I hereby certify according to employment records and to the best of my knowledge, that the above information is true and
correct.
Signature of Supervisor
Printed Name
SUBSCRIBED AND SWORN to me this
day of
,
.
Notary Public
SEAL
My Commission Expires:
Two witness signatures required if notary not available:
Witness Signature:
Witness Signature:
08-4151c (Rev. 8/00)
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