- Nevada State Board of Optometry

Request for Location Change Form test payment

NEVADA STATE BOARD OF OPTOMETRY
- Post Office Box 1824
- Carson City, Nevada 89702
- Telephone: (775) 883-8367
- Facsimile: (775)305-0105
- E-Mail: admin@nvoptometry.org
Request for Address/Location Change
Name*
First
License #*
Email Address*
Phone*
Is this now your primary location?*
- Yes
- No
Do you have a Nevada Optometry License Certificate to hang at this location?*
- No, I need to request a Duplicate Certificate.
- Yes, I am no longer practicing at
Addr./Loc. Change Fee*
Price:
Location Change Fee
Price:
Duplicate License Certificate
Price:
Please make all checks to the Nevada State Board of Optometry and mail them to P.O. Box 1824, Carson City, NV 89702.
Total
$0.00
*
- By submitting this information and checking this box, I affirm that each document is complete and correct and that all information contained in this submission is true under the pains and penalties of perjury and the requirements of NRS Chapter 636 and NAC Chapter 636 and Nevada law generally.I also acknowledge that if I have directed or authorized a person to complete or submit this information on my behalf, I, the optometrist licensed by the Nevada Board of Optometry, am fully responsible for the content of the submission.
Name*
First
Date*
MM slash DD slash YYYY
Billing Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Credit Card
NOTE: Payments may be made by mail, enclosing a check payable to NV State Board of Optometry, noting the purpose of the payment and the name of the license. However, the Board prefers that all applications, documents or forms be submitted electronically. No submissions will be processed or deemed submitted until payment has been received.
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Request for Location Change Form test payment

NEVADA STATE BOARD OF OPTOMETRY

Request for Address/Location Change

Privacy Policy