Form Od-01 1016r - Application For Exam & License - Optometrist Page 5
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6OPTOMETRIST
APPLICATION FOR EXAM & LICENSE -
$242/$107
Access this form via website at: cca.hawaii.gov/pvl
diploma - Optometry school
Read "Requirements for License" before completing this form.
NBEO - Part I (after 1987)
Legal Name (First, Middle):
(Last):
NBEO - Part II (after 1987)
NBEO - Part III (after 1991)
Other Names Used (including maiden name):
License Verification
Date Licensed:
License No.:
OD -
Residence Address (include apt. no., city, state & zip code):
Business Address (include suite no., city, state & zip code):
Phone No. (days)
Mailing Address (ONLY if different from residence address):
Res:
Bus:
Social Security No.:
Date of Birth:
Check answers. If response to questions 8, 9, or 10 is "YES", refer to instructions for additional documents that must be submitted with this
application.
1.
Are you at least 18 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
2.
Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
Are you a graduate of an American optometric school recognized and approved by the
3.
YES
NO
American Optometric Association? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
Did you pass the NBEO Parts I and II after 1987 and Part III after 1991? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
5.
At the time you took the NBEO exam, did you arrange to have the examination results sent to the Hawaii Board? . . . .
YES
NO
Provide date you requested results:
6.
Are you licensed to practice optometry in any other state in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
State(s) licensed in:
Date(s) licensed:
7.
Do you wish to be licensed through reciprocity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
What state are you basing your reciprocity on?
8.
Has any license ever been suspended, revoked, or otherwise subject to disciplinary action? . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
9.
Are there any disciplinary actions pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
10.
Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged? . . . . . . . . . . . . . .
YES
NO
(SIGNATURE REQUIRED ON PAGE 2)
Appl . . . . . . . . . . . . . . . 454 . . . . . . . . . . . . . . . . $15
CRF . . . . . . . . . . . . . . . . 458 . . . . . . . . . . . . . . . . $50/$100
Lic . . . . . . . . . . . . . . . . . 456 . . . . . . . . . . . . . . . . $42
1/2 Renewal . . . . . . . 450 . . . . . . . . . . . . . . . . $85
Service Fee . . . . . . . . BCF. . . . . . . . . . . . . . . . $25
OD-01 1016R
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