Form Doh 662-097 - Optometrist License Application Packet Page 14
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27(To be Completed by the Regulatory Agency)
Please complete this form regarding the applicant listed on the reverse. Submit the completed
form and any other requested material directly to this office at the address on the reverse. We
will not accept the form if submitted by the applicant. Thank you.
Name of license, certification, or registration holder:
Authority providing verification: (state, name & title)
Applicant was credentialed by: Date:
Score:
Written Examination
F
Name of examination:
Date:
Score:
Other Examination
F
Name of examination:
Is credential current: F Yes F No
Expiration Date:
Is this individual considered to be in good standing in your state? F Yes F No
If “no,” please attach explanation.
Has this credential ever been denied?
F Yes F No
Suspended?
F Yes F No
Revoked?
F Yes F No
Surrendered?
F Yes F No
Reinstated?
F Yes F No
If “yes,” please provide a copy of the final order or other documentation of action taken.
If this credential holder has been disciplined, has he/she successfully completed all
requirements and is currently in good standing? F Yes F No
Signature:
(SEAL)
Title:
Date:
DOH 662-062 April 2017
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