Original License Application - Maryland Board Of Examiners In Optometry Page 2
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16ORIGINAL LICENSE APPLICATION
Applicant Information
Last Name:
First Name:
Middle:
Current address:
City:
State:
Zip Code:
Home number:
Mobile number:
Email address:
Date of birth:
SSN:
OE Tracker #:
_____/_________/_________
Male ________________
Female _____________________
Veteran and Spousal Preference
1.
Are you an active duty service member or the spouse of an active duty service member? Yes ________ No ________
2.
Are you a veteran or the spouse of a veteran who was discharged from active duty under circumstances other that dishonorable
within one (1) year of filing this application? Yes ___________ No ___________
Race/Ethnic Identification- Please check all that apply
Are you of Hispanic or Latin origin Yes ______________ No ________________
Select one or more of the following racial categories:
American Indian/Alaskan Native ________ Asian ___________ Black or African American ________
Native Hawaiian or other Pacific Islander _________ White ________
Other __________
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