Form Dh-Mqa 1128 - Application For Licensure As Certified Optometrist (Page 2 of 11) in pdf

Section 456.0635(2), Florida Statutes, requires a different set of criminal history questions. Some of your

answers may appear to overlap other questions on this application. Please read each question carefully and

completely. Some of the questions will direct you to skip the following question(s), if your answer is "no".

Please follow the instructions. Again, "yes” answers require the documentation mentioned above.

FEES:

OPTOMETRY LICENSURE EXAMINATION:

Application Fee:

$ 250.00

Initial Licensure Fee:

$ 300.00

Unlicensed Activity Fee:

5.00

Laws & Rules

$ 100.00

Department Administrative Costs*

$ 655.00

TOTAL FEE:

UPGRADE OPTOMETRIST TO CERTIFIED OPTOMETRIST - ONLY: (Non-Certified Optometry only)

Application Fee:

$ 250.00

Duplicate License Fee:

$ 25.00

TOTAL FEE:

$ 275.00

OPTOMETRY COLLEGE TRANSCRIPT:

A final official transcript stating the degree and date of confirmation must be sent directly from the optometry school/college to

this office. Transcripts submitted by the applicant or indicating “issued to student” are not acceptable. A copy of your diploma is

not acceptable. Please note that it is your responsibility to follow-up with your educational institutions to ensure that they have

received and complied with your requests.

LICENSURE VERIFICATION:

The licensure verification forms included with this application package must be sent to each state or other licensing authority

where you currently hold or have held a license to practice, regardless of the status of the license. These forms must be sent

directly from each state licensing agency to this office. Please note that it is your responsibility to follow-up with licensing

agencies to ensure that they have received and complied with your requests. A copy of your license will not be accepted in lieu

of official verification from the licensing agency.

NATIONAL BOARD OF EXAMINERS IN OPTOMETRY (NBEO) SCORES:

Official NBEO Scores for parts I (ABS), II (PAM – which includes the TMOD) and III must be sent directly from National

Board to this office. Again, please note that it is your responsibility to follow-up with NBEO to ensure that they have received and

complied with your requests.

OE TRACKER NUMBER: Please provide this number during your application process.

FOREIGN EDUCATION EQUIVALENCY REQUIREMENTS:

All foreign graduates who intend to utilize credit earned in colleges or universities outside of the United States to qualify for

licensure will need to provide evidence of U. S. equivalency of such credit hours. The credentials evaluation must be performed by

one of the acceptable credential evaluation services and include a breakdown of all college level courses by subject. Credit hours

must be listed in semester hours. The credentials evaluation should be sent directly to the board office from the evaluator. If

transcripts cannot be ordered from the foreign institution, certified copies of the original documents used in the evaluation must be

submitted to the agency.

ACCEPTABLE FOREIGN CREDENTIALS EVALUATION SERVICES:

JOSEF SILNY & ASSOCIATES

FOUNDATION FOR INTERNATIONAL

INTERNATIONAL EDUCATIONAL

SERVICES, INC.

CONSULTANTS

14926 35

AVENUE WEST, SUITE 210

7101 SW 102 AVENUE

LYNWOOD, WA 98087

MIAMI, FL 33173

PHONE: (425) 248-2262

PHONE: (305) 273-1616

FAX: (425)248-2262

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P a g e s

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 Page 2

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