Application For An Optometry License - New Jersey State Board Of Optometrists Page 11
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13New Jersey Office of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Optometrists
124 Halsey Street, 6th Floor, P.O. Box 45012
Newark, New Jersey 07101
(973) 504-6440
Active Status Form
Please complete either the Active Status or the Inactive-Paid Status form.
An applicant applying for a license on active status must have a business address within the State of New Jersey in which he or
she will be practicing. Please provide your name of record, business name, business address and business telephone number.
Please print clearly.
Name of record ______________________________________________________________________________________________
Last name
First name
Middle initial
Business name _______________________________________________________________________________________________
Business address _____________________________________________________________________________________________
Street address
City
State
ZIP code
Business telephone number _________________________________
(include area code)
Check one:
Pay $250 for the active-status license if applying for licensure during the first year of the biennial renewal period.
(Applying between May 1st of every odd year through February 20th of every even year.)
Pay $125 for the active-status license if applying for licensure during the second year of the biennial renewal
period. (Applying between May 1st of every even year through February 20th of every odd year.)
___________________________________
__________________________________________
Date
Applicant’s signature
Please Note
If you are submitting your application to the Board between February 21st through April 30th of any year, please call the Board
office at 973-504-6440 for the appropriate licensure fee or submit your application without the licensure fee and you will be
notified in writing of the appropriate licensure fee.
When applying for an optometry license on active status and an Oral T.P.A. Certification at the same time, you are only required
to pay one nonrefundable application filing fee of $125.00.
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