Form Doh 662-097 - Optometrist License Application Packet printable pdf download

Form Doh 662-097 - Optometrist License Application Packet

Optometrist License Application Packet

Contents:

1. 662-097 ....Contents List/SSN Information/Mailing Information .........................1 page

2. 662-079 ....Application Instructions Checklist ..................................................2 pages

3. 662-103 ....Certification Requirements ............................................................2 pages

4. 662-092 ....Optometrist License Application ....................................................5 pages

5. 662-062 ....Out-of-State Credential Verification ...............................................2 pages

6. 662-078 ....Jurisprudence Exam ......................................................................8 pages

7. 662-095 ....Optometry Certification for Diagnostic,

Therapeutic and Oral Drugs ............................................................1 page

8. 662-096 ....Optometry Certification for Administration of Epinephrine

by Injection for Treatment of Anaphylactic Shock ...........................1 page

9. RCW/WAC and Online Website Links ..............................................................1 page

Important Social Security Number Information:

You are required by state and federal law to provide a social security number with your

application. If you do not have a social security number at the time you send in this

application, please read, complete, and return this

form

with your application.

A U.S. Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance

Number (SIN) cannot be substituted.

In order to process your request:

Mail your application with Initial

documentation and your check

Send other documents not sent

or money order payable to:

with initial application to:

Department of Health

Optometry Credentialing

P.O. Box 1099

P.O. Box 47877

Olympia, WA 98507-1099

Olympia, WA 98504-7877

360-236-4700

DOH 662-097 April 2017

Form Doh 662-097 - Optometrist License Application Packet