Form Doh 662-097 - Optometrist License Application Packet Page 4

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you do not provide this, your application is incomplete and it will not be considered.
y Question 5 includes misdemeanors, gross misdemeanors and felonies. You do
not have to answer yes if you have been cited for traffic infractions. You can get
copies of court records through the county courthouse where the conviction,
plea, deferred sentence, or suspended sentence was entered.
If you have been granted certificate(s) of restoration of opportunity, please
provide a certified copy of each certificate.
y Another jurisdiction means any other country, state, federal territory, or military
authority.
F 3. Other License, Certification, or Registration:
List all states where credentials are or were held. Attach additional pages if you
need more space.
F 4. Professional Education:
List in date order, most recent to later, your educational preparation and post-
graduate training. Attach additional pages if you need more space.
F 5. Professional Experience:
List in date order all professional experience and practice from date of graduation
from professional college. Attach additional pages if you need more space.
F 6. Qualifications Attestation:
You must meet the qualification requirements. You must sign and date this
application as proof of completion.
F 7. AIDS Education and Training Attestation:
Read the AIDS education and training attestation. AIDS training may include self-
study, direct patient care, courses, or formal training. A minimum of four hours is
required. Course content can be found in
WAC
246-12-270. If AIDS education
was included in your professional education or training, an additional course is not
required.
F 8. Endorsement Attestation:
If you are applying by endorsement you must sign and date this for us to process
the application. See
WAC 246-581-500
F 9. Applicant’s Attestation:
You must sign and date this for us to process the application.
For Spouses and Registered Domestic Partners of Military
Personnel Being Transferred or Stationed in Washington:
Under state law, if you are the spouse or state-registered domestic partner of a
servicemember of any branch of the U.S. Military, to include Guard or Reserve, and
are applying for a health care professional credential in this state, you may be eligible
to have the processing of your application expedited to receive your credential more
quickly.
Documents to submit with your application should include the following:
A copy of your spouse’s or registered domestic partner’s military transfer orders
to Washington State.
One of the following:
-
A copy of your marriage certificate to show proof of marriage; or
-
A copy of a state’s declaration or registration showing you are in a state
registered domestic partnership with a member of the U.S. military.
DOH 662-079 April 2017
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