Form 08-4232 - Optometry License Application Page 10
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18PART VII
Notarized Signature with Photograph
I certify that the information on this form is true and correct to the best of my knowledge and that all credentials supplied
by me to support my application are true and correct. The Division may deny, suspend, or revoke the license of a
person who has obtained or has attempted to obtain a license by fraud or deceit. The person may also be subjected to
criminal charges for perjury or unsworn falsification. (AS 11.56.210)
Printed Name:
Date:
Sign Before a Notary:
Notary Public for State of:
Subscribed and Sworn to Before
me on this Day:
Notary’s Signature:
My Commission Expires:
Photograph
Attach a recent photo that is no
larger than 3” x 3”.
Notary Stamp
The notary seal must overlie a
portion of the photograph.
08-4232
Rev. 12/01/16
Application Page 6 of 6
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