Fillable Form 08-4232 - Optometry License Application (Page 9 of 18) in pdf

PART VI

Professional Background

(continued)

Professional Fitness

The following questions must be answered. “Yes” answers may not automatically result in license denial.

For each “Yes” response to any question, you must provide an explanation and documentation. Provide your

explanation on a separate sheet of paper labeled with your name, and signed by you; include full details, dates,

locations, type of action, organizations or parties involved, and specific circumstances. Documentation includes

copies of court orders, charging documents, board or license actions, etc. When in doubt about your response,

disclose and provide the required explanation and documents.

Applications submitted without the required attachments will be considered incomplete and will not be processed.

CONFIDENTIALITY

The contents of licensing files are generally considered public records. If you believe that the additional information

you are attaching to explain a “yes” answer should be considered confidential, state that in the attachment. A request

for confidentiality may or may not be granted.

WHEN IN DOUBT, DISCLOSE AND EXPLAIN

Have you been convicted of a crime or are you currently charged with committing

a crime? For purposes of this question, “crime” includes a misdemeanor, felony,

or a military offense, including, but not limited to, a conviction involving driving

under the influence (DUI) or driving while intoxicated (DWI), driving without a

Yes

license, reckless driving, or driving with a suspended or revoked license.

“Convicted” includes having been found guilty by verdict of a judge or jury, having

entered a plea of guilty, nolo contendere or no contest, or having been given

probation, a suspended imposition of sentence, or a fine.

Have you had a professional license denied, revoked, suspended, or otherwise

restricted, conditioned, or limited or have you surrendered a professional license,

been fined, placed on probation, reprimanded, disciplined, or entered into a

Yes

settlement with a licensing authority in connection with a professional license you

have held in any jurisdiction including Alaska and including that of any military

authorities or is any such action pending?

Are you now or have you been in the last five years diagnosed with or treated for

bipolar disorder, schizophrenia, paranoia, psychotic disorder, substance abuse,

Yes

depression (except for situational or reactive depression) or any other mental or

emotional illness?

Are you now or have you been in the last five years been treated for, or addicted

Yes

to, or excessively used, or misused, alcohol, narcotics, barbiturates or habit-

forming drugs?

Do you have a physical disability or illness, which could affect your ability to

Yes

practice as an optometrist?

If you checked “Yes” to any of the above questions, you must attach a detailed explanation. You must also

have your treating physician submit a letter directly to the Board regarding your ability to practice safely and

competently.

08-4232

Rev. 12/01/16

Application Page 5 of 6

Form 08-4232 - Optometry License Application Page 9

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