State of Alaska
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
REFERENCE
I certify that I am acquainted with or have knowledge of
Name of Applicant
from
to
. I recommend
Month
Day
Year
Month
Day
Year
the applicant as being professionally capable, reliable, and worthy of confidence.
PERSONAL STATEMENTS:
Signature
Date
Title
Address
Daytime Telephone
SUBSCRIBED AND SWORN before me, a Notary Public in and for the State of
this
day of
,
.
Notary Public
My Commission Expires:
08-4232a (Rev. 1/00)