Application For Optometry License Renewal - Nevada State Board Of Optometry (Page 2 of 3) in pdf

Application For Optometry License Renewal - Nevada State Board Of Optometry Page 2

Do you have a Nevada business license in compliance with the provisions of NRS Chapter 76?

☐ Yes ☐ No

If “Yes,” provide your State of Nevada business license number: _________________________.

Under what name is your business license held?

___________________________________________________________________________________________________________________

Have you ever served in the Military?

☐ Yes ☐ No

If “Yes,” please provide your date(s) of service: From__________________________To___________________________________

(DD-MM-YYYY)

Branches of Service (Check all that apply)

Army/Army Reserve

☐

Marine Corps/Marine Corps Reserve

☐

Navy/Navy Reserve

☐

Air Force/Air Force Reserve

☐

Coast Guard/Coast Guard Reserve

☐

National Guard

☐

RENEW an ACTIVE LICENSE

Name:

License Number:

Mailing Address:

E-Mail: ________________________________________________ Phone: _________________________________________________

Enclosed is my payment in the total amount of $_______________.

_____

The enclosed payment represents the $375.00 license renewal fee for the 2018-2019 license

year for my primary practice location at:

___________________________________________________________________________________

Phone: ________________________________ FAX: ____________________________________

_____

If you are practicing in the State, and have more than one location, the renewal fee is

assessed per location. Please include an additional $175.00 to renew each of your

additional practice locations for the 2018-2019 license year, and list them below.

1.________________________________________________________________________________

___________________________________________________________________________________

Phone: ________________________________ FAX: ____________________________________

Application For Optometry License Renewal - Nevada State Board Of Optometry Page 2