Application For An Optometry License - New Jersey State Board Of Optometrists Page 10
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13C
ertifiCation
I, ______________________________________________, in making this application to the Board or Committee for
certification or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufficient to deny certification or licensure or to withhold renewal of or suspend or revoke a certificate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualifications for certification or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, files or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________
_________________________________
Signature of applicant Date
Rev. 10/1/16
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