Completion of this application form is necessary for consideration for licensure under Chapter 636 of
the Nevada Revised Statutes. Disclosure of this information is voluntary. Failure to disclose all
requested information may result in this form not being processed and may subsequently result in
denial of this application.
All candidates for licensure have an obligation to update and supplement the information and
responses on this application if they change. Failure to supplement the information and responses
provided on this application may result in denial or other appropriate action. All information
provided must be accurate. Please note that the information provided on this application is subject
to the public information laws of the State of Nevada. Carefully follow the directions on this
Your application is NOT complete until all supporting documents and fees have been received by the
Nevada State Board of Optometry.
Complete this section of the form by providing all requested information. You must notify the Board of Optometry, in writing, of any address changes that occur after you file the application.
Starting with your undergraduate education, list all schools, colleges, and universities attended in chronological order:
If you have ever been licensed, certified, or registered to practice optometry in any other jurisdiction,
complete the information requested below. You must include jurisdictions within and outside the United
States. Failure to disclose all licenses, certifications, or registrations held may result in denial of your
application, or other appropriate action.
Complete each of the following items. List all employment chronologically for the past five (5) years
beginning with the most recent. Explain any breaks in employment history of greater than six months.
In accordance with NRS 636.159 applicants for licensure must certify under penalty of perjury:
By virtue of filing this application, I do solemnly swear or affirm that I am of good moral character, and that I
understand the instructions and terms set forth in this application is true, correct, and complete to the best of
my knowledge, and that the photograph attached hereto is a true likeness of myself. I hereby authority the
Nevada State Board of Optometry to verify any and all information contained in this application, including
information maintained in applicable data banks. This application and signature shall act as authorization of
entities in possession of applicable information to release such information to the licensing authority.”