Form Doh 662-097 - Optometrist License Application Packet Page 7
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27Date
Stamp
Here
Revenue 0261010000
Optometrist License Application
Please print clearly. It is the responsibility of the applicant to submit all supporting documentation. Failure to do so
may result in a delay in processing your application.
Select if the following applies:
F Spouse or Registered Domestic Partner of Military Personnel
1. Demographic Information
National Provider Identifier Number
Social Security Number
(NPI)
(SSN)
F Male
(Enter 10 digit number)
(If you do not have a SSN, see instructions)
F Female
Name
First
Middle
Last
Birth date (mm/dd/yyyy)
Place of birth
City
State
Country
Address
City
State
Zip Code
County
Country
Phone (enter 10 digit #)
Fax (enter 10 digit #)
Cell (enter 10 digit #)
Email address
Mailing address if different from above address of record
City
State
Zip Code
County
Country
Note: The mailing and email addresses you provide will be your addresses of record. It is your responsibility to
maintain current contact information on file with the department.
Have you ever been known under any other name(s)? F Yes F No
If yes, list name(s):
Will documents be received in another name? F Yes
F No
If yes, list name(s):
DOH 662-092 April 2017
Page 1 of 5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal