Form Doh 662-097 - Optometrist License Application Packet Page 13
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27Optometry Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
Out-of-State Credential Verification
To Applicant:
Please complete this side of this form and send it to the state(s) and/or jurisdiction(s) where
you are or have been licensed, certified, or registered as a healthcare provider. The regulatory
agency will complete page two.
Name:
Last
First
Middle
Mailing Address
City
State
Zip Code
Phone (enter 10 digit #)
Cell (enter 10 digit #)
Email address
Any other names used:
Type of license(s) you hold or have held in other state(s):
Washington State healthcare credential type you are applying for:
Washington State healthcare credential number (if available):
Date Issued
Have the licensing agency complete page two and return this form to the address listed above.
If you have any questions, please call 360-236-4700.
This form may be duplicated.
DOH 662-062 April 2017
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