Form Dh-Mqa 1128 - Application For Licensure As Certified Optometrist printable pdf download

APPLICATION FOR LICENSURE

AS CERTIFIED OPTOMETRIST

PLEASE READ CAREFULLY

FLORIDA LAWS & RULES:

You may download a copy of Chapter 463, Florida Statutes and Rule Title 64B13, Florida Administrative Code at

It is important to read this in order to determine your eligibility prior to applying, and to

familiarize yourself with the statutes and board rules regarding your application for licensure and the practice of the optometric

profession within the State of Florida.

APPLICANT'S QUESTIONS REGARDING APPLICATION STATUS:

Within thirty (30) days after we receive your application and fee, we will send you an acknowledgment letter informing you of any

deficiencies in your application and the specific items required to complete your application. If you do not receive notice that we

have received your application within forty-five (45) days of the date you mailed it, or if you have questions concerning the

requirements for licensure, please do not hesitate to contact this office. If you have questions concerning whether or not we have

received items which we require you to arrange to be sent to this office by a third party (such as official transcripts, licensure

verifications from state licensing agencies); please check with the third party first to see if the required documentation has been

sent. As a reminder to all applicants, Chapter 456.013(1)(a), Florida Statutes, provides that an incomplete application shall expire

one year after initial filing with the department.

YES/NO QUESTIONS:

All questions with a "Yes or No” answer must be marked with either a "Yes" or "No." No other response is acceptable. For

questions which require a brief explanation or description to “Yes” answers, your responses must be sufficiently detailed to

ascertain the relevant dates, institution/organization names, and a brief synopsis of the reasons (i.e., the final charges or

substantiated allegations only) the institution/organization took the disciplinary or other action (i.e., probation, limitation,

suspension, revocation, voluntary relinquishment in lieu of disciplinary action, or any other adverse action). HOWEVER, IF A

QUESTION CONTAINED IN THIS APPLICATION IS NOT APPLICABLE ANSWER “N/A” IN THE NO COLUMN.

DISCIPLINARY AND CRIMINAL HISTORY

Please read each question carefully. Answer questions with “YES,” “NO,” OR “N/A.” Do not leave questions unanswered. A

“YES” answer may require you to make a personal appearance before the Board of Optometry “YES” answers to any question

in the Disciplinary and Criminal History section require the following additional documentation:

1. A written statement explaining in detail the circumstances surrounding the "YES" answer. The statement must include all

pertinent information such as date(s), explanation(s), address(es), employer(s), physician(s), institution(s).agency(ies) and

hospital(s). The statement should be attached to your application. Be sure to number the statement to correspond with the

question it explains.

2. Supporting documentation must also be submitted to verify the events, including court documents for each offense.

providing arrest records, restitution or current circumstances, final disposition, etc. If the records are no longer available, you

must have certification of their unavailability from the court.

3. For documents regarding discipline or termination, the issuing agency must send the information as it pertains to the action.

If discipline was issued, then the agency should send a copy of the administrative complaint and the final order to this office.

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DH-MQA 1128, Revised 07/16

Rule 64B13-4.004 & 64B13-10.001, F.A.C.

Form Dh-Mqa 1128 - Application For Licensure As Certified Optometrist