Original License Application - Maryland Board Of Examiners In Optometry Page 15
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16Verification of State Licensure Con’t
State Exam. Date of Exam: ___________/_______/____________ Describe: ____________________
Reciprocity or
Endorsement. From which State or Jurisdiction? ____________________________
Other. Please explain. ______________________________________________________________
F.
Continuing Education
a. Is mandatory continuing education required for license renewal ?
YES
NO
b. If yes, what is the number of hours required annually? ____________________________
G. Licensure Status
a. What type of optometry license does this optometrist hold in your state
BASIC
DIAGNOSTIC
THERAPEUTIC
b. Is this license current and in good standings?
YES
NO Please explain__________
H. Disciplinary Action
a. Has your state ever taken any disciplinary action against this licensee’s license?
YES
NO
b. If yes, briefly explain t he final action taken, the date executed, and provide a copy of the
Settlement Agreement, Decision and Order, or Stipulation and Order in the matter.
_____________________________________________________________________________________
____________________________________________________________________________________
Date: _________/_______/___________
I.
List Attachments for Item H __________________________________________________________
Signature: ___________________________________
Print Name: __________________________________
Title: ________________________________________
State Board: __________________________________
Address: ___________________________________
___________________________________________
Phone No. (_______) _______-________
Date: _______/______/________
State Seal
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