Application For Optometry License Renewal - Nevada State Board Of Optometry printable pdf download

Application For Optometry License Renewal - Nevada State Board Of Optometry

NEVADA STATE BOARD OF OPTOMETRY

WILIAM F. HARVEY, O.D.

Post Office Box 1824

SHERESE SETTELMEYER

Board President

Carson City, Nevada 89702

Public Board Member

Telephone: (775) 883-8367

CHEN K. YOUNG, O.D.

Facsimile: (775) 883-1938

MARIAH L. SMITH, O.D.

Board Member

E-Mail:

Board Member

CAREN C. JENKINS, ESQ.

Executive Director

APPLICATION FOR OPTOMETRY LICENSE RENEWAL

THE FOLLOWING QUESTIONS MUST BE COMPLETED AND THE APPLICATION

MUST BE SIGNED. FAILURE TO ANSWER THE QUESTIONS AND/OR SIGN THE

FORM WILL RESULT IN THE DENIAL OF YOUR APPLICATION, AND THE

RETURN OF YOUR RENEWAL DOCUMENTS.

In support of my application for renewal of my license to practice optometry in the

State of Nevada, by my signature at the conclusion of this application

_____________________________________________________, License Number __________, state my responses

herein are true to the best of my knowledge and ability:

Are you currently obligated by Court Order for the payment of child support?

☐ Yes ☐ No

Are you current in your obligations under any Court ordered child support?

☐ Yes ☐ No

Between March 1

, 2016 and the date of this application, has the DEA disciplined your certification,

or have you ever voluntarily surrendered it, allowed it to lapse, or had a limited certificate issued?

☐ Yes ☐ No

Do you have or have you ever had any licensing jurisdiction, DEA or a state drug enforcement

authority take disciplinary action against you?

☐ Yes ☐ No

If yes, when and where? ______________________________________________________________________________________

Have you been convicted of any drug or alcohol related offense by a Court of competent jurisdiction

between March 1

, 2016, and the date of this application?

☐ Yes ☐ No

If yes, when and where? _______________________________________________________________________________________

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

☐ Yes ☐ No

Application For Optometry License Renewal - Nevada State Board Of Optometry

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