Form Dh-Mqa 1128 - Application For Licensure As Certified Optometrist (Page 4 of 11) in pdf

Form Dh-Mqa 1128 - Application For Licensure As Certified Optometrist Page 4

RESCHEDULING:

•

You may reschedule your examination appointment as needed, without penalty, up to two days prior to your examination.

•

If you attempt to reschedule your examination within two days of your appointment, you will be considered a “late

cancel.” You must then wait at least three (3) days from the date of your appointment before you may reschedule your

examination. You will be required to repay the examination fee.

•

One form of valid, current, government-issued identification with both a signature and a photo.

•

Driver’s License; OR

•

State I.D. card; OR

•

Military I.D.; OR

•

Passport

NOTE: The name on your eligibility record (from your examination application submitted to the Board Office) must match the

name on the ID you present at the Prometric testing center. If these names do not match, you will not be allowed to test. To

change the name on your eligibility record, contact the Board Office.

Note:

If an applicant has not been issued a Social Security number, the department may process the application. However,

only a temporary license, which expires in 30 days, will be issued. Upon receipt of a Social Security number a new license

will be issued.

If the package that you are mailing to the Board Office contains money, mail to:

DEPARTMENT OF HEALTH

Post Office Box 6330

Tallahassee, Florida 32314-6330

If the package that you, or anyone on your behalf, is mailing to the Board Office does NOT contain money, mail to:

Board of Optometry

4052 Bald Cypress Way, Bin #C07

Tallahassee, Florida 32399-3257

FEDERAL PRIVACY ACT:

Under the Federal Privacy Act, disclosure of social security numbers is voluntary unless specifically required by federal statute. In

this instance, social security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654: and

sections 456.013, 409.257(7) and 409.259(8), F. S. Social security numbers are used to allow efficient screening of applicants and

licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social security numbers must also

be recorded on all professional and occupational license applications and will be used for license verification pursuant to, unless

exempt as outlined in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.

L. 193, Section 317.

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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 4

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