Form Dh-Mqa 1128 - Application For Licensure As Certified Optometrist (Page 7 of 11) in pdf

Form Dh-Mqa 1128 - Application For Licensure As Certified Optometrist Page 7

EMAIL ADDRESS:

(Email Notification: If you want to notified of the status of your application by email please check the “YES” box and write your email address on the line

provided above. If you choose this form of notification you will receive information regarding your application file through email. You will be responsible

for checking your email regularly and updating your email address with the board office

mqa_optometry@doh.state.fl.us

. Under Florida law, email

addresses are public records. If you do not want your e-mail address released in response to a public records request, do not provide an email address or

[ ] YES [ ] NO

send electronic mail to our office. Instead contact the office by phone or in writing.

PERSONAL DATA:

BIRTH DATE:

(Month/Day/Year)

CITIZENSHIP:

We are required to ask that you furnish the following information as part of your voluntary compliance with Section 2, Uniform Guidelines on Employee

Selection Procedure (1978) 43 FR 38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any

way

affect your candidacy for licensure.

RACE: [ ] Caucasian [ ] African-American/Black [ ] Hispanic [ ] Asian [ ] Native American [ ]

Other SEX: [ ] Male [ ] Female

•

Would you be willing to provide health services in special needs shelters or to help staff disaster medical

assistance teams during times of emergency or major disaster?

[ ] YES [ ] NO

APPLICANT EDUCATION AND TRAINING DATA:

Optometric Education:

(Name of School(s) you attended)

[ ] YES [ ] NO