Original License Application - Maryland Board Of Examiners In Optometry Page 3
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16Education
(Practices optometry for at least 500 hours within 3 consecutive years)
Name and Address of undergraduate college(s)/University attended and total credits and degree.
Name of College or University:
Address:
Education
State:
Zip Code:
City:
A. Have you engaged in active practice immediately before applying for licensure?
Date of Graduation:
Total # of Credits:
Type of Degree:
Yes ___________
No _____________
Name of College or University:
State _____________________
License Number_______________________
Address:
Expiration Date _______/_______/________
State:
Zip Code:
City:
If yes, please attach the active practice affidavit to the application. This notarized affidavit may be completed by a
colleague, employer, business associate, etc. Forward the attached Active Practice Affidavit to the licensure boards in
each state in which you are now licensed or have been licensed. The other state board is to return this form if necessary.
Type of Degree:
Total # of Credits:
Date of Graduation:
School of Optometry
Name of School of Optometry:
Address:
necessary.
ir
Zip Code:
ectl
State:
City:
y to the Maryland Board of Optometry. You may reproduce this form if necessary.
Date of Graduation:
Degree:
References
As to character and reputation, I refer you to the following three named persons, (all non-relatives), who have known me over two (2)
years. A letter from each of these people must be sent directly to the Board Office.
The continuing education requirements of the other state (s) in which the applicant has been practicing shall meet the
Name:
Address:
equivalent of 3 years of the continuing education requirements in courses approved by the Board.
Does the state (s) in which you now hold a license require continuing education? Yes _____ No_____
Name:
Address:
Number of hours required annually ________
A letter from your licensing Board requiring continuing education must accompany this application to substantiate the hours you have
Name:
Address:
earned in the past 3 years. If your present state Board does not require continuing education hours, you must submit documentation
of continuing education hours equivalent to the exact number of hours a Maryland practitioner for the last 3 years, i.e. total 54 hours.
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