Form Od-01 1016r - Application For Exam & License - Optometrist Page 2

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RECIPROCITY

All states or jurisdictions in which the applicant is licensed have provided certified statements that the license of

(cont'd)

the applicant has not been and is not currently in the process of being investigated, suspended, or revoked by

that state for any cause which constitutes grounds for revocation, suspension, or refusal to issue a license as

specified in Chapter 459, HRS.

NOTE: If you are unable to apply for licensure via reciprocity because your state does not reciprocate with

Hawaii and/or the educational requirements of your originating state are not equivalent or greater than that

of Hawaii, you may apply for licensure by meeting the education and examination requirements.

DOCUMENTS

Proof of Education: A certified copy of your diploma or certificate of graduation from an optometric college,

REQUIRED FOR

school, or university approved by the Board and accredited by a regional or professional accreditation

ALL APPLICANTS

organization and recognized by the council on post-secondary accreditation or by the United States

Department of Education.

NBEO Score Report: Request the NBEO send an official score report directly to the Board. An application to

request a score report can be found on the internet at the website below or by contacting them directly.

National Board of Examiners in Optometry

Phone: 800-969-EXAM

200 S. College Street, #2010

Website:

Charlotte, NC 28202

Email:

ADDITIONAL

License Verification: Have the licensing authority of each state/jurisdiction in which you hold a license,

DOCUMENTS

complete the "Verification of License" form (OD-02) and send it directly to the Board. Make copies of this form,

REQUIRED FOR

as needed.

RECIPROCITY

APPLICANTS

Check with the licensing authority for any fees you may need to pay and also the length of time for that agency

to process your license verification to our State.

Education Requirements: A copy of the educational requirements of the originating state at the time your

license in that state was granted.

FEES

Attach appropriate fee. Make check payable to: COMMERCE & CONSUMER AFFAIRS. (check must be in U.S. dollars

and be from a U.S. financial institution.)

If license is issued in an EVEN-NUMBERED year, pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$242

(Application fee-$15* + License fee-$42 + Compliance Resolution Fund-$100 +

1/2 Renewal-$85)

If license is issued in an ODD-NUMBERED year, pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $107

(Application fee-$15* + License fee-$42 + Compliance Resolution Fund-$50)

*Application fee is not refundable.

NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued is the

payment of fees as set forth in this application. You may be sent a license certificate before the check you sent us for your

required fees clears your bank. If your check is returned to us unpaid, you will have failed to pay the required licensing fee

and your license will not be valid, and you may not do business under that license. Also, a $25.00 service fee will be

charged for checks which are returned by the bank.

If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by Title 16,

Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written request for a hearing

must be directed to the agency that denied your application, and must be made within 60 days of notification that your

application for a license has been denied.

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