Application For A License To Practice Optometry (By Examination Or Reciprocity) Page 7
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7Version: July 2017
State Board of Optometry
State Board of Optometry
2601 North Third Street
P O BOX 2649
Harrisburg PA 17110
Harrisburg PA 17105-2649
BUREAU OF PROFESSIONAL
AND OCCUPATIONAL AFFAIRS
VERIFICATION OF OPIOID EDUCATION
APPLICANT INFORMATION
NAME:
Last
First
Middle
OTHER NAME(S):
LAST 4 DIGITS OF SSN:
DATE OF BIRTH :
ADDRESS:
CITY / STATE / ZIP:
OPTOMETRY BOARD-APPROVED CE PROVIDER INFORMATION
NAME OF PROGRAM/PROVIDER:
ADDRESS:
CITY, STATE, ZIP:
PHONE NUMBER:
PRINT NAME OF DIRECTOR / PROVIDER:
EMAIL ADDRESS OF DIRECTOR / PROVIDER:
The following information must be completed by the Director of the Optometry Program, a Board-approved advanced
pharmacology course provider, or the continuing education provider and must verify that the applicant successfully
completed at least 2 hours of education in pain management or the identification of addiction and 2 hours of education
in the practices of prescribing or dispensing of opioids.
I hereby certify that the above listed applicant successfully completed 2 hours of education in pain management or the
identification of addiction and 2 hours of education in the practices of prescribing or dispensing of opioids on
_____/_____/__________.
Month
Day
Year
I verify that the above statements are true and correct as validated by my review of the applicant’s records. I
verify that the information communicated on this form is true and correct to the best of my knowledge, information and
belief. I understand that any false statement made is subject to the penalties of 18 Pa. C.S. §4904, relating to unsworn
falsification to authorities.
Date: Month
Day
Year
Original Signature Director / Provider:
RETURN THIS FORM TO:
STATE BOARD OF OPTOMETRY
PO BOX 2649
HARRISBURG, PA 17105
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