Form Doh 662-097 - Optometrist License Application Packet Page 11
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277. Qualifications and Training Attestation
I certify I have completed each of the requirements below.
A high school diploma or equivalent;
y
Applicant’s Initials
Date
I am of moral character.
y
8. Endorsement Attestation
(only required for endorsement applicants.)
I certify that I have read the following rules and laws pertaining to the practice of Optometry in Washington
State as stated in
WAC
246-851-500:
RCW 18.53
y
Applicant’s Initials
Date
y
RCW 18.54
RCW 18.195
y
y
RCW 18.130
WAC 246-851
y
y
WAC 246-852
9. Applicant’s Attestation
I, ___________________________________ , declare under penalty of perjury under the laws of the state
(Print applicant name clearly)
of Washington the following is true and correct:
•
I am the person described and identified in this application.
RCW 18.130.170
RCW 18.130.180
•
I have read
and
of the Uniform Disciplinary Act.
•
I have answered all questions truthfully and completely.
•
The documentation provided in support of my application is accurate to the best of my knowledge.
•
I have read all laws and rules related to my profession.
I understand the Department of Health may require more information before deciding on my application. The
department may independently check conviction records with state or federal databases.
I authorize the release of any files or records the department requires to process this application. This includes
information from all hospitals, educational or other organizations, my references, and past and present
employers and business and professional associates. It also includes information from federal, state, local or
foreign government agencies.
I understand I must inform the department of any past, current or future criminal charges or convictions. I will
also inform the department of any physical or mental conditions that jeopardize my ability to provide quality
health care. If requested, I will authorize my health providers to release to the department information on my
health, including mental health and any substance abuse treatment.
Dated ______________________________ By: ____________________________________________
(mm/dd/yyyy)
(Original Signature of Applicant)
DOH 662-092 April 2017
Page 5 of 5
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