Application For A License To Practice Optometry (By Examination Or Reciprocity) (Page 4 of 7) in pdf

Version: July 2017

YES

12.

Will any documentation submitted in connection with this application be received in a name



other than the name under which you are applying?

If you answered YES, please provide the name or names. Submit a copy of the legal

document evidencing the name change (i.e., marriage certificate, divorce decree or court

order).

13.

Do you hold, or have you ever held, a license, certificate, permit, registration or other



authorization to practice ANY health-related profession in any state or jurisdiction?

If you answered YES to the above question, please provide the profession and state or

jurisdiction. Please do not abbreviate the profession.

The Board must receive verification of any license, certificate, permit, registration or other authorization to

practice a profession or occupation directly from the state or jurisdiction. PLEASE NOTE: The Board

does NOT need to receive verification for licenses issued by one of the licensing boards within the

Pennsylvania Bureau of Professional and Occupational Affairs.

If you answered YES to any of the following questions, provide complete details as well as

YES

copies of relevant documents to the Board office.

14.

Have you had disciplinary action taken against a professional or occupational license,



certificate, permit, registration or other authorization to practice a profession or occupation

issued to you in any state or jurisdiction or have you agreed to voluntary surrender in lieu of

discipline?

15.

Do you currently have any disciplinary charges pending against your professional or



occupational license, certificate, permit or registration in any state or jurisdiction?

16.

Have you withdrawn an application for a professional or occupational license, certificate, permit



or registration, had an application denied or refused, or for disciplinary reasons agreed not to

apply or reapply for a professional or occupational license, certificate, permit or registration in

any state or jurisdiction?

17.

Have you been convicted (found guilty, pled guilty or pled nolo contendere), received probation



without verdict or accelerated rehabilitative disposition (ARD), as to any criminal charges,

felony or misdemeanor, include any drug law violations? Note: You are not required to

disclose any ARD or other criminal matter that has been expunged by order of a court.

18.

Do you currently have any criminal charges pending and unresolved in any state or



jurisdiction?

19.

Have you engaged in or have you ever engaged in the intemperate or habitual use or abuse of



alcohol or narcotics, hallucinogenics or other drugs or substances that may impair judgment or

coordination?

20.

Have you had your DEA registration denied, revoked or restricted?



21.

Have you had provider privileges denied, revoked, suspended or restricted by a Medical



Assistance agency, Medicare, third party payor or another authority?

22.

Have you had practice privileges denied, revoked, suspended or restricted by a hospital or any



health care facility?

23.

Have you been charged by a hospital, university, or research facility with violating research



protocols, falsifying research, or engaging in other research misconduct?

Application For A License To Practice Optometry (By Examination Or Reciprocity) Page 4

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