Form Dh-Mqa 1128 - Application For Licensure As Certified Optometrist (Page 9 of 11) in pdf

Optometry Applicant Name:

OE TRACKER #

Are you currently listed on the United States Department of Health and Human Services Office

of Inspector General's List of Excluded Individuals and Entities?

[ ] YES [ ] NO

10.

Have you ever been declared legally incompetent?

[ ] YES [ ] NO

If YES, please explain in full on attached sheets as to court date and circumstance and

medical practitioners consulted.

11. Have you ever been arrested or criminally or civilly charged with any intentional or negligent action related to

the use or misuse of drugs, alcohol, or illegal chemical substances?

[ ] YES [ ] NO

12.

Have you ever been denied the right to take an Optometry Licensure Examination in any state?

[ ] YES [ ] NO

13.

Have you ever been refused a license to practice optometry or any other license or the renewal thereof in any state?

[ ] YES [ ] NO

14.

Have you had a license or certification of registration to practice optometry or any other licensed profession revoked,

suspended or otherwise acted against (including probation, fine, reprimand or surrender of license) in a disciplinary

proceeding in any state?

[ ] YES [ ] NO

15.

Is there currently pending against you, in any jurisdiction, a complaint against your professional conduct or

competence as an optometrist?

[ ] YES [ ] NO

16.

Have you served in the Armed Forces?

[ ] YES [ ] NO

If yes, Enlistment Date

Separation Date

Type of Discharge

17. Do you now hold or have you held a license to practice optometry in any state, US territory or foreign country?

[ ] YES [ ] NO

a. Have you ever been convicted or found guilty, regardless of adjudication, of a crime in any jurisdiction, or have

[ ] YES [ ] NO

you ever been a defendant in a military court-martial? (Do not include parking or speeding violations)

If yes,

State

License Number

18.

[

]

I am applying to take the Certified Optometrist Examination based on graduation from an approved school or college of optometry

which has certified to the Board that graduates received 110 hours of approved coursework in general and ocular pharmacology,

including clinical training and at least one year of supervised experience in differential diagnosis of eye diseases or disorders.

[

]

University of Alabama

1973

[

]

University of Missouri

1984

[

]

University of California (Berkeley)

1977

[

]

Southern College

1976

[

]

Southern California College

1979

[

]

NEWENCO

1977

[

]

Ferris State College

1979

[

]

Northeastern State

1983

[

]

Pennsylvania College

1976

[

]

Ohio State

1972

[

]

Waterloo, Canada

1976

[

]

Pacific University

1977

[

]

University of Houston

1975

[

]

Illinois College

1976

[

]

State University of New York

1975

[

]

Nova Southeastern

1993

[

]

Indiana University

1976

[

]

Inter-American University

1985

[

]

University of Montreal

1983

(Puerto Rico)

[

]

Midwestern University Arizona

2013

[

]

University of the Incarnate

Word Rosenberg

2013

[

]

Western University of Health Sciences 2013

9 of 12 |

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 9

Related Articles

Related forms

Related Categories