Original License Application - Maryland Board Of Examiners In Optometry Page 13
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16APPLICATON FOR THE USE OF THERAPEUTIC PHARMACEUTICAL AGENTS
Applicant Information
First Name:
Middle Initial:
Last Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Home Number:
Mobile Number:
Email Address:
Optometry School:
Date of Graduation:
City:
State:
Zip Code:
A TPA Certified Optometrist in Maryland must complete 50 hours of continuing education during the two-year period that the license is active and 30 hours
shall be in the use and management of TPAs. A TPA Certified Optometrist shall be certified in CPR and shall verify this certification upon request from the
Board.
AFFIDAVIT
The undersigned, being duly sworn deposes and says that he or she is the person who executed this application; that the statements
contained herein are true and correct to the best of his or her knowledge and belief; that he or she has not suppressed any
information that might affect this application; that he or she will abide by the ethical standards and conduct of this profession; and
has read and understands this affidavit. I certify that the attached photograph is a true likeness of the applicant.
APPLICANT’S SIGNATURE _____________________________________________ DATE ____/____/___
NOTARY PUBLIC DOCUMENTATION
State of __________________________________ County of ________________________________
Sworn before me this _______________ day of________________________________, 20 _________
Notary Public Signature ____________________________________________
Notary
My commission expires
___________/____________/__________________
Seal
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