PART IV - Personal History Information
PART V - Work History/Practical Experience
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.
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PART VI - Child Support Information
In accordance with NRS 636.159 applicants for licensure must certify under penalty of perjury:
PART VII - Certifying Statement
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. My responses are is true, correct, and complete to the best of my knowledge, and that the photograph attached hereto is a recent, true likeness of me. I hereby authorize the Nevada State Board of Optometry to verify any and all information contained in this application, including information maintained in relevant professional or other data banks. This application and electronic signature shall serve as authorization of entities in possession of applicable information to release such information to the licensing authority.”
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AFFIDAVIT IN SUPPORT OF APPLICATION FOR LICENSURE
being first duly sworn, depose and state as follows:1. I have completed the Application for Licensure as a Doctor of Optometry by Endorsement as provided by Chapter 636 of the Nevada Revised Statutes;2. All information contained in the application is true and correct;4. I have been actively engaged in the practice of optometry for the immediate past five (5) years;5. I have had no adverse actions on my optometry license reported to the National Practitioner Data Bank in the past five (5) years;6. I have not been disciplined nor am I currently under investigation by the corresponding regulatory authority of the District of Columbia or any state or territory in which I currently hold or have held a license to engage in the practice of optometry; and7. I have not been held criminally liable for malpractice in the District of Columbia or any state or territory of the United States.
Price: $300.00
(includes $75 application fee and $225.00(includes for 2 year license and certificate)
Price: $0.00
$0.00
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NOTE: To avoid the 3.5% credit card processing fee, payments may be made by mail, enclosing a check payable to NV State Board of Optometry, noting the purpose of the payment. The Board prefers that all applications, documents or forms be submitted electronically. No submissions will be processed or deemed submitted until the Board receives payment.
Upload a recent, clearly recognizable passport-size photograph (2 x 2 inches) with a maximum file size of 240KB
Attach a copy of a current CPR card
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