Form Doh 662-097 - Optometrist License Application Packet Page 3
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27Application Instructions Checklist
Important background check Information: Washington State law authorizes the
Department of Health to obtain fingerprint-based background checks for licensing
purposes. This check may be through the Washington State Patrol and the Federal
Bureau of Investigation (FBI). This may be required if you have lived in another state or
if you have a criminal record in Washington State. This would be at your own expense.
All information should be printed clearly. It is your responsibility to submit the correct
forms required.
F Application Fee. This fee is non-refundable. You can check the online
fee page
for current fees.
F Select if the following applies:
Spouse or Registered Domestic Partner of Military Personnel
F 1. Demographic Information:
Social Security Number: You must list your social security number on your
application. Please call the Customer Service Center at 360-236-4700 if you do not
have one.
National Provider Identifier Number (NPI): The National Provider Identifier (NPI)
is a standard unique identifier for health care professionals available from the
Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric
identifier. If you have a NPI number, provide this on your application.
Legal Name: List your full name: first, middle, and last.
Definition of legal name: “Legal name” is the name appearing on your official
certificate of birth or, if your name has changed since birth, on an official marriage
certificate or an order by a court. The court must have the legal authority to change
your name. We may ask you to prove your legal name. If you use any name other
than your legal name on this form, your application may be denied.
Birth date: Provide the month, day, and year of your birth.
Birth place: Provide the city, state, and country where you were born.
Address: List the address we should use to send any information about your
license. Be sure to include the city, state, zip code, county, and country. This will be
your permanent address with the Department of Health until we have been notified
WAC
246-12-310.
of a change. See
Phone, Fax, and Cell Numbers: Enter your phone, fax and cell numbers, if you
have them.
Email: Enter your email address, if you have one.
Other Name(s): Indicate whether you are known or have been known under any
other names. If you have a name change, you must notify the Department of
Health in writing. You must include proof of this change. See
WAC
246-12-300.
F 2. Personal Data Questions:
All applicants must answer the same personal data questions. They are focused on
your fitness to practice the essential skills of this profession. If you answer “yes” to
any questions in this section, you must provide an appropriate explanation.
You must also provide the documentation listed in the note after the question. If
DOH 662-079 April 2017
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