Application For A License To Practice Optometry (By Examination Or Reciprocity) printable pdf download

Version: July 2017

STATE BOARD OF OPTOMETRY

P.O. Box 2649

Harrisburg, PA 17105-2649

Telephone: (717) 783-7155

Courier Address:

Fax: (717) 787-7769

2601 North Third Street

Website:

Harrisburg, PA 17110

E-Mail: st-optometry@pa.gov

APPLICATION FOR A LICENSE TO PRACTICE OPTOMETRY

(BY EXAMINATION OR RECIPROCITY)

***REQUIREMENTS FOR LICENSE***

Graduation from an accredited optometric educational institution in the United States or Canada**.

Passing score on the National Board of Examiners in Optometry (NBEO) examinations

Part I – Applied Basic Science

Part II – Patient Assessment and Management

Part III – Clinical Skills

TMOD – Treatment and Management of Ocular Disease

** REQUIREMENTS FOR GRADUATES OF UNACCREDITED OPTOMETRIC EDUCATIONAL INSTITUTIONS

In addition to all other requirements, graduates of unaccredited optometric educational institutions must:

1. Submit their credentials to an accredited optometric educational institution.

2. Make up any deficiencies (if applicable).

3. Obtain certification from the accredited optometric educational institution that the requirement for graduation from

the accredited school have been met.

***APPLICATION CHECKLIST***

ALL APPLICANTS ARE REQUIRED TO:

(Check when completed)



Complete pages 1, 2 and 3 of the application.



Application Fee: $25.00 check or money order made payable to “Commonwealth of PA.”

PLEASE NOTE THE FOLLOWING:

* Application fees are not refundable.

* A processing fee of $20.00 will be charged for any check or money order returned unpaid by your

bank, regardless of the reason for non-payment.



The Bureau of Professional and Occupational Affairs (BPOA), in conjunction with the Department of Human

Services (DHS), is providing notice to all health-related licensees and funeral directors that are considered

“mandatory reporters” under § 6311 of the Child Protective Services Law (CPSL) (23 P.S. § 6311), as

amended, that EFFECTIVE JANUARY 1, 2015, all persons applying for issuance of an initial license shall be

required to complete 3 hours of DHS-approved training in child abuse recognition and reporting requirements

as a condition of licensure. Please review the Board website for further information on approved CE

providers. Once you have completed a course, the approved provider will electronically submit your name,

date of attendance, etc., to the Board.

Child Abuse Continuing Education Providers Information can be found

here.



If you answered YES to any of the criminal/disciplinary action questions, please provide accurate details on

separate 8 ½” x 11” sheets of paper and provide copies of court documents.



If any documentation submitted in connection with this application will be received in a name other than the

name under which you are applying, you must submit a copy of the legal document(s) indicating the name

change (i.e., marriage certificate, divorce decree which indicates the retaking of your maiden name; legal

document indicating the retaking of a maiden name, or court order).

Application For A License To Practice Optometry (By Examination Or Reciprocity)

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