Continuing Education ("Ce") Audit Form - Board Of Examiners In Optometry
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1FOR OFFICE USE
ONLY
TPA Certified
BOARD OF EXAMINERS IN OPTOMETRY
Professional & Vocational Licensing Division
Deficient
Department of Commerce and Consumer Affairs
Supporting documents
P.O. Box 3469
needed
Honolulu, Hawaii 96801
Compliant Filed _____
(808) 586-2693
Email: optometry@dcca.hawaii.gov
CONTINUING EDUCATION (“CE”) AUDIT FORM
Course date*
Course title
Sponsor
Credit Hours
TOTAL:
*C.E. credit hours acquired/effective during the January 1, 2016 to December 31, 2017 period.
I hereby certify that all information contained in this audit form and the supporting documents attached are true and correct.
OD -
_______________________________________________________________________
_____________________________
Print Name:
License No.
_______________________________________________________________________
_____________________________
Signature of Licensee
Date
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