Original License Application - Maryland Board Of Examiners In Optometry (Page 5 of 16) in pdf

Original License Application - Maryland Board Of Examiners In Optometry Page 5

PHOTOGRAPH

Attach a recent passport type

photograph (2”x2”)

Applicant must sign the back of

the photograph

AFFIDAVIT

The undersigned, being duly sworn deposes and says that he or she is the person who executed this application; that the statements

contained herein are true and correct to the best of his or her knowledge and belief; that he or she has not suppressed any information

that might affect this application; that he or she will abide by the ethical standards and conduct of this profession; and has read and

understands this affidavit. I certify that the attached photograph is a true likeness of the applicant.

APPLICANT’S SIGNATURE _____________________________________________ DATE_____/______/______

Mail completed application and $300.00 fee, payable to:

The Maryland Board of Optometry

4201 Patterson Avenue, Room 307

Baltimore, MD 21215-2299

NOTARY DOCUMENTATION

State of __________________________________ County of __________________________________

Sworn before me this _______________ day of _____________________, 20 _________

Notary Public Signature _______________________________________________________

Expiration Date ___________/____________/__________________

Notary Seal

For Office Use Only

Date App. Rec’d_____/____/_____ Check # __________ Check Date _____/____/_____ Check Amount $_____

Date Application Approved _____/ ____/___ License# _____________ TPA_____ DPA_________

Reinstate Date: ______/_____/_____ Upgrade Date: TPA __/____/___ DPA: ___/____/____

Under Graduate Transcript (s)____________________ Optometry School Transcript___________________

Photo: _____ Law Exam Score:__________ Photocopy of Diploma: _____________ Licensure Affidavit (s): _____________

NBEO Scores: Part I _____Part 2_______ Part 3____ TMOD _______

Copy of Current License(s): _______________

CPR:_______ Certification Application: DPA ____ TPA ____ 3 Letters of Recommendations _______________

Original License Application - Maryland Board Of Examiners In Optometry Page 5