Form Od-01 1016r - Application For Exam & License - Optometrist Page 4

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iii.

If applicable, a copy of the terms of probation and/or parole and a notarized statement from your probation or parole officer as to

your compliance with the court orders;

iv.

A current criminal history record check in your name from the state where the conviction occurred and the state where you

currently reside, if different. In Hawaii, you may obtain a criminal history record check from the Hawaii Criminal Justice Data

Center. Contact the Department of the Attorney General, Hawaii Criminal Justice Data Center, Kekuanao'a Building, 456 S. King

Street, Room 102, Honolulu, HI 96813. Ph: (808) 587-3279 or visit their website at: ag.hawaii.gov/hcjdc. For other states/

jurisdictions, contact the local authority or Board for their forms, instructions and fees on obtaining a criminal history record

check.

If you answered "YES" to any of the questions (8) through (10), your application may be reviewed at a Hawaii Board of Examiners in

Optometry meeting if you have provided all applicable information and documents as described above. The Board will not review

incomplete applications. If you wish to present oral testimony at the meeting, submit a written request with your application.

RELEASE OF

If an agency or individual is assisting you with the licensure process, we will not be able to release any information to

INFORMATION

them unless you provide us with authorization. If you wish to do so, please complete the portion on "Release of

Information to Third Party", sign and date it.

ABANDONMENT OF

Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be destroyed if you fail to

APPLICATION

provide evidence of continued efforts to complete the licensing process for two consecutive years. The failure to

provide evidence of continued efforts includes but is not limited to: (1) failure to submit any required information

and documents requested by the licensing authority within two consecutive years from the last date the documents

and information were requested, or (2) failure to complete any additional requirements for licensure that remain

after approval of your application, such as attempting to complete an examination requirement, within two

consecutive years from the date your application was approved, or (3) failure to provide the licensing authority with

any written communication during two consecutive years indicating that you are attempting to complete the

licensing process. If an application is deemed abandoned the applicant shall be required to reapply for licensure and

comply with the licensing requirements in effect at the time of the reapplication.

Print Form

This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.

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