Form Od-01 1016r - Application For Exam & License - Optometrist Page 6
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6Print Name of Optometrist:
Date:
Affidavit of applicant:
I hereby certify that the answers, statements and representations made in this application and the documents attached are true and
correct. I understand that any misrepresentation is grounds for refusal or subsequent revocation of license and is a misdemeanor (Section
710-1017, Sections 436B-19 and 459-9, Hawaii Revised Statutes). I further certify that I have read, understand and will abide by the laws and
rules concerning optometry in the State of Hawaii.
Signature of Applicant
Date
Release of Information to Third Party:
To assist me in the licensing process, I hereby authorize DCCA's staff to release any and all information regarding my application
(including, but not limited to application status) to the following third party:
Print name of Individual who is assisting you:
Name of Organization:
Signature of Applicant
Date
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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