Pharmaceutical Agent Prescription And Use Endorsement For Diagnostic And Therapeutic Drugs Form printable pdf download

Pharmaceutical Agent Prescription And Use Endorsement For Diagnostic And Therapeutic Drugs Form

OPT

State of Alaska

FOR OFFICE USE ONLY

Department of Community and Economic Development

Division of Occupational Licensing

Board of Examiners in Optometry

P.O. Box 110806

Juneau, Alaska 99811-0806

(907) 465-2580

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

PHARMACEUTICAL AGENT PRESCRIPTION

AND USE ENDORSEMENT FOR

DIAGNOSTIC AND THERAPEUTIC DRUGS

The $100.00 endorsement fee must be attached.

Please mark appropriate box:

TPA Endorsement (Therapeutics and Diagnostics)

DPA Endorsement (Diagnostics only)

Name:

Daytime Telephone:

Address:

Street

City

State

ZIP Code

DPA ENDORSEMENT

I certify that I passed the National Board of Examiners in Optometry (NBEO) examination IN or AFTER 1988;

I certify that I have passed section 9 of the NBEO examination prior to 1988.

TPA ENDORSEMENT

I certify that I have passed: (check at least one)

TMOD Examination administered by the National Board of Examiners in Optometry (NBEO) within the last:

2 years

5 years - enclose continuing education documentation per 12 AAC 48.025(b)

Verification of passage of the TMOD Examination must be mailed to the division directly from the NBEO.

The examination required for completion of a board approved pharmacology and ocular disease course of at least

100 contact hours offered by an accredited school or college of optometry within the last:

2 years

5 years - enclose continuing education documentation per 12 AAC 48.025(b)

Verification of passage of the 100-hour course and examination must be mailed to the division directly from the

optometry college.

I HEREBY CERTIFY that the information contained in this application for the pharmaceutical endorsement is true and correct

to the best of my knowledge. I further certify that all credentials supplied by me are true and correct. I understand that any

false information or falsification of credentials may result in failure to obtain a pharmaceutical agent prescription and use

endorsement in the State of Alaska, as well as discipline action against my optometry license, itself. I further certify that I have

read and understand the following statutes and regulations regarding the therapeutic endorsement:

AS 08.72.175,

AS 08.72.272, 12 AAC 48.025 and 12 AAC 48.021 (attached to this application).

Signature of Applicant

Date

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

this

day of

Notary Public

08-4232e (Rev. 1/00)

My Commission Expires:

Pharmaceutical Agent Prescription And Use Endorsement For Diagnostic And Therapeutic Drugs Form

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