Application For An Optometry License - New Jersey State Board Of Optometrists Page 12
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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
Inactive-Paid Status Form
Please complete either the Active Status or the Inactive-Paid Status form.
If you are not going to be practicing in the State of New Jersey or you do not currently have a promise of employment in the
State of New Jersey, you must apply for a license on inactive-paid status. Please provide your name of record and your mailing
address below.
Please print clearly.
Name of record ______________________________________________________________________________________________
Last name
First name
Middle initial
Mailing address ______________________________________________________________________________________________
Street address
City
State
ZIP code
Check one:
Pay $100 for the inactive-paid 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 $50 for the inactive-paid 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 inactive-paid status, you cannot apply for an Oral T.P.A. Certification until you have
a promise of employment and request to transfer your inactive-paid license to an active status.
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