Application For An Optometry License - New Jersey State Board Of Optometrists Page 6
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138. Have you ever changed your name?
Yes
No
If “Yes,” please submit with this application a copy of the marriage certificate, divorce decree or court order.
9. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.)
Yes
No
10. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea
of guilty, non vult, nolo contendere, no contest, or a finding of guilt by a judge or jury.
Yes
No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
11. Have you served in the Armed Forces of the United States?
Yes
No
If “Yes,”what type of military discharge did you receive? Indicate the type of discharge you received.
________________________________________________________________________________________________________
12.
Do you currently hold, or have you ever held, a professional or occupational license or certificate of any kind in New Jersey, any other
state, the District of Columbia or in any other jurisdiction?
Yes
No
If “Yes,” for each license or certificate held, provide the date(s) held and the number(s). If the license was issued under a
__________________________________________________________________
different name, please provide that name.
Last name
First name
Middle initial
_____________________
_______________________
____________________________
____________________
Type of license or certificate
Number
State or jurisdiction that issued the license or certificate
Date issued/expired
_____________________
_______________________
____________________________
____________________
Type of license or certificate
Number
State or jurisdiction that issued the license or certificate
Date issued/expired
_____________________
_______________________
____________________________
____________________
Type of license or certificate
Number
State or jurisdiction that issued the license or certificate
Date issued/expired
13. Have you ever taken any other state board or regional board’s exam and failed?
Yes
No
If “Yes,”please provide the name of the state and the date the exam was taken.
_____________________________________________________
___________________________________
State
Date
14. Have you ever been cited for disciplinary reasons or denied a professional or occupational license or certificate of any kind
in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes
No
15. Have you ever had a professional or occupational license or certificate of any type suspended, revoked or surrendered in
New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes
No
16. Has any action (including the assessment of fines or other penalties) ever been taken against your professional or occupational
practice by any agency or certification board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes
No
17. Have you ever been named as a defendant in any litigation related to the practice of optometry or other professional or
occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes
No
18. Are you aware of any investigation pending against a professional or occupational license or certificate issued to you by a professional
or occupational board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes
No
19. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any
other jurisdiction?
Yes
No
20. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional or
occupational group related to the practice of optometry or other professional or occupational practice in New Jersey, any
other state, the District of Columbia or in any other jurisdiction?
Yes
No
If the answer to any of the above questions, numbers 14 through 20, is “Yes,” provide a complete explanation of the
circumstances leading to the action, and any supporting documentation, on separate sheets of paper.
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