Original License Application - Maryland Board Of Examiners In Optometry Page 14
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16VERIFICATION OF LICENSURE FORM
INSTRUCTIONS TO APPLICANT:
P l e a s e f i l l o u t o n l y t h e t o p p o r t i o n o f t h i s f o r m a n d s e n d i t t o t h e s t a t e b o a r d ( s ) i n w h i c h y o u
a r e n o w l i c e n s e d o r h a v e e v e r b e e n l i c e n s e d ( N o t e : F e e m a y be a p p l i c a b l e ) .
Last Name _____________________________ First Name ______________________________MI __
Address ________________________________City _________________State____ Zip Code_____
Social Security No _________-_______-________ Date of Birth _________/________/_________
I (print) ____________________________________________________________ hereby authorize the
(State) ______________________________________________________________________ Board
to release information regarding my License No __________________ as a (n) ____________________
FOR VERIFYING BOARD USE ONLY
Verification of State Licensure
A. (State Board) ______________________________________________________________________________
B. Licensee’s Name as it appears on your records_____________________________________________
C. License No and Initial Issue Date ____________________
________/_______/________
D. License Expiration Date________/_______/________; If license has lapsed, Lapse Date: ____/____/____
E.
Licensure By (Please check applicable item and supply information requested):
NBEO Exam
Part I
________________
Score _______________
Part II ________________
Score _______________
Part III _________________
Score _______________
TMOD __________________
Score _______________
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