Original License Application - Maryland Board Of Examiners In Optometry Page 4
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16Answer all Questions
Yes________ No _________
1.
Have you ever been refused examination by a State Board?
Yes ________ No _________
2.
Have you previously taken the Maryland Board of Licensure Examination?
Year ______________
If yes, date taken __________________________
3. Have you ever failed an examination before a Board or have you ever been refused a license?
Yes _________ No ________
If yes, provide details.
Yes _________ No _________
3.
Has your license to practice in any state ever been revoked or suspended?
If yes, provide details.
5. I have been licensed to practice optometry in other State(s)?
Yes _________ No ________
State ______________________________
License Number _________________________
State _______________________________
License Number _____________________
6. If you have practiced in another state, list locations and years of practice
State _______________________________
# of Years_______________________________
Yes _________ No _________
7. Have you ever pled guilty, nolo contendere, or been convicted or received probation before
judgment of any criminal act (excluding traffic violations)?
If yes, please explain and submit all legal documentation.
8. Are you addicted to the use of narcotics or intoxicants?
Yes _________ No _________
9. Maryland requires passage of the NBEO Examination, Part I, Basic Science; Part II, Clinical Science; Part III, Patient Care and TMOD
Treatment and Management of Ocular Disease; for licensure. An official copy of your scores must be forwarded to the Board Office.
Examination
Date
Part I ____________________
_____________________
Part II ___________________
____________________
Part III ___________________
_____________________
TMOD ___________________
_____________________
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