Form Doh 662-097 - Optometrist License Application Packet Page 9

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2. Personal Data Questions (cont.)
Yes No
6. Have you ever been found in any civil, administrative or criminal proceeding to have:
a. Possessed, used, prescribed for use, or distributed controlled substances or legend
drugs in any way other than for legitimate or therapeutic purposes? .................................................F F
b. Diverted controlled substances or legend drugs? ................................................................................F F
c. Violated any drug law? .........................................................................................................................F F
d. Prescribed controlled substances for yourself? ....................................................................................F F
7. Have you ever been found in any proceeding to have violated any state or federal law or rule
regulating the practice of a health care profession? If “yes”, please attach an explanation and
provide copies of all judgments, decisions, and agreements? ................................................................ F F
8. Have you ever had any license, certificate, registration or other privilege to practice a health care
profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? ............. F F
9. Have you ever surrendered a credential like those listed in number 8, in connection with or to
avoid action by a state, federal, or foreign authority? .............................................................................. F F
10. Have you ever been named in any civil suit or suffered any civil judgment for incompetence,
negligence, or malpractice in connection with the practice of a health care profession? ........................ F F
11. Have you ever been disqualified from working with vulnerable persons by the Department
of Social and Health Services (DSHS)? .................................................................................................. F F
3. Other License, Certification, or Registration
List all states where licenses are or were held. Specifically list licenses granted as temporary, reciprocity,
exemption or similar with type, date, grantor, and if license is current. Attach additional pages if you need more
space.
License
Method
License
License
State/Jurisdiction
Number
Issue Date
Expiration Date
Licensed
Type
DOH 662-092 April 2017
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