Form Doh 662-097 - Optometrist License Application Packet (Page 10 of 27) in pdf

Form Doh 662-097 - Optometrist License Application Packet Page 10

4. Professional Education

In the spaces below, provide a date listing of your educational preparation and post-graduate training.

Attach additional pages if you need more space.

Attendance

Schools Attended

Degree

Full Name, City and State

Earned

From (mm/dd/yyyy)

To (mm/dd/yyyy)

5. Professional Experience

List in date order all professional experience and practice from date of graduation from professional college.

Include the month/day/year. Attach additional pages if you need more space.

Start Date

End Date

Nature of experience and location

(mm/dd/yyyy)

6. AIDS Education and Training Attestation

I certify I have completed the minimum of four hours of education in the prevention, transmission and

treatment of AIDS, which included the topics of etiology and epidemiology, testing and counseling, infection

control guidelines, clinical manifestations and treatment, legal and ethical issues to include confidentiality, and

psychosocial issues to include special population considerations.

I understand I must maintain records documenting said education for two years and be prepared to submit

those records to the department if requested. I understand should I provide any false information, my

license may be denied, or if issued, suspended or revoked. If AIDS

Applicant’s Initials

Today’s Date

education was included in your professional education or training, an

additional course is not required.

DOH 662-092 April 2017

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Form Doh 662-097 - Optometrist License Application Packet Page 10