Application for License by Endorsement

APPLICATION FOR LICENSURE AS A DOCTOR BY ENDORSEMENT AS PROVIDED BY CHAPTER 636 OF THE NEVADA REVISED STATUTES

IMPORTANT NOTICE:

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 application form.

In addition, note the following:

Type or print legibly with blue or black ink only;
The application/examination fee is NOT refundable;
Disclosure of your U.S. Social Security Number, if you have one, is mandatory. This disclosure is mandated by NRS 636.157; and
If the name shown on your supporting documents is different from that on your application, you must submit proof of legal name change, a certified copy of your marriage license, divorce decree, affidavit or court order.

Supporting Documentation and Fees:

$250 application/examination fee
Wallet or passport size colored photo taken within 30 days of the submission of this application

Your application is NOT complete until all supporting documents and fees have been received by the Nevada State Board of Optometry.

PART I - Applicant’s Identifying Information

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.

Name*

Last Name

*

First Name

MI

*

Suffix

Social Security Number*

Current Address

Street Address City State ZIP Code

Permanent Mailing Address, including postal code if different from current address listed above

Street Address City State ZIP Code

Identify Preferred Mailing Address*

Current
Permanent

Note: You must select one. The preferred mailing address will be available to the public.

Identify each maiden name, surname, or any other names or aliases you have been known by or used, and identify the reason for your name change.*

Place of birth (City, County, State, other jurisdiction, Country)*

Date of Birth*

Contact Information

Telephone Numbers*

Daytime

Evening

E-Mail Address*

Citizenship

Are you a citizen of the United States?*

Yes
No

If you are not a citizen, are you ?*

A qualified alien (as defined in 8 U.S.C.A. Sec. 1641)
A nonimmigrant under the Immigration and Nationality Act (8 U.S.C.A. Sec. 1101, et seq.)
An alien who is paroled into the U.S. under 8 U.S.C.A. Section 1128(d)(5) for less than one year
A foreign national not physically present in the United States
Other – Please provide a detailed explanation

Do you intend to seek entry into the United States for the purpose of performing labor as a healthcare worker, other than an optometrist?*

Yes
No

Military Service

Have you ever served in the Military?*

Yes
No

Date of Service*

From

*

To

Branch(es) of service: (Check all that apply)*

Army/Army Reserve
Marine Corps/Marine Corps Reserve
Navy/Navy Reserve
Coast Guard/Coast Guard Reserve
National Guard
Air Force/Air Force Reserve

Military Occupation Specialty/Specialties?*

Has your spouse ever served in the Military?*

Yes
No

Date of Service*

From

*

To

Branch(es) of service: (Check all that apply)*

Army/Army Reserve
Marine Corps/Marine Corps Reserve
Navy/Navy Reserve
Coast Guard/Coast Guard Reserve
National Guard
Air Force/Air Force Reserve

Military Occupation Specialty/Specialties?*

PART II - Education Information

1. Name of Last Secondary School Attended*

Location of Last Secondary School Attended*

Year of Graduation

or Year G.E.D. Earned

Please list jurisdiction where earned

2. Post Secondary Education History:

Starting with your undergraduate education, list all schools, colleges, and universities attended in chronological order:

PART III - Record of Licensure Information

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.

PART IV - Personal History Information

1. Have you ever had an application for any professional license refused or denied by any licensing authority?*

Yes
No

2. Have you ever been refused or denied the privilege of taking an examination required for any professional licensure?*

Yes
No

3. Have you ever voluntarily surrendered your optometry license?*

Yes
No

4. Have you ever allowed your optometry license to lapse, or had a limited license issued by any optometric authority?*

Yes
No

5. Have you ever voluntarily surrendered any other professional license?*

Yes
No

6. Have you ever allowed any other professional license to lapse, or had a limited license issued by any other licensing authority?*

Yes
No

7. Have you ever been the subject of disciplinary action with regard to your optometry license?*

Yes
No

8. Has your optometry license ever been revoked?*

Yes
No

9. Have you ever had any other professional license revoked?*

Yes
No

10. Have you ever been the subject of disciplinary action by any licensing agency with regard to any other professional license?*

Yes
No

11. To your knowledge, have any unresolved or pending complaints been filed against you with any optometric licensing authority?*

Yes
No

12. Have you ever had a registration issued by a controlled substance authority revoked, suspended, surrendered, limited, or restricted?*

Yes
No

13. Have you ever voluntarily surrendered a registration issued by a controlled substance authority?*

Yes
No

14. Has your application for accreditation by the DEA ever been denied?*

Yes
No

15. Has the DEA ever disciplined your certification, or have you ever voluntarily surrendered it, allowed it to lapse, or had a limited certificate issued by the DEA:*

Yes
No

16. Is there any disciplinary action pending against you by any licensing jurisdiction, drug enforcement agency, or any state drug enforcement authority?*

Yes
No

When and Where?

17. Have you been charged with or convicted (including a nolo contendere plea or guilty plea) of a felony (or criminal offense in any state or federal court (other than minor traffic violations) whether or not sentence was imposed or suspended?*

Yes
No

18. Have you ever been pardoned from a felony (or criminal) conviction?*

Yes
No

19. Have you ever had a record expunged from a felony (or criminal) conviction?*

Yes
No

20. Have you ever been charged with or convicted (including a nolo contendere plea or guilty plea) of a violation of any federal or state drug law(s) or rule(s) whether or not sentence was imposed or suspended?*

Yes
No

21. Are you being treated or have you, in the last 5 years, been treated for drug or alcohol addiction or participated in a rehabilitation program?*

Yes
No

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.

1. Name of Business/Institution

Address/Phone Number of Business/Institution

Dates of Employment

From

To

Job Title

Name of Supervisor

Reason for termination/resignation

Description of Duties Performed

2. Name of Business/Institution

Address/Phone Number of Business/Institution

Dates of Employment

From

To

Job Title

Name of Supervisor

Reason for termination/resignation

Description of Duties Performed

3. Name of Business/Institution

Address/Phone Number of Business/Institution

Dates of Employment

From

To

Job Title

Name of Supervisor

Reason for termination/resignation

Description of Duties Performed

4. Name of Business/Institution

Address/Phone Number of Business/Institution

Dates of Employment

From

To

Job Title

Name of Supervisor

Reason for termination/resignation

Description of Duties Performed

PART VI - Child Support Information

In accordance with NRS 636.159 applicants for licensure must certify under penalty of perjury:

1. I currently have no obligation for child support*

Yes
No

2. I am currently obligated by Court Order for the payment of child support*

Yes
No

3. I am obligated to pay child support, and have had arrearages on my obligation*

Yes
No

4. Currently there is an arrearage on my child support obligation*

Yes
No

5. I am currently repaying a child support arrearage pursuant to an agreement with the District Attorney or other public enforcement agency, and my ongoing monthly payment is current*

Yes
No

If you chose “2” you must choose the response that applies to your child support obligation. Failure to choose a response will result in the denial of your application.

Attach Photo

Upload a recent, clearly recognizable passport-size photograph(2 x 2 inches) .

File size should be maximum 240KB

CPR Card

Attach a copy of a current CPR card

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 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.”

Name*

First

Date*

AFFIDAVIT IN SUPPORT OF APPLICATION FOR LICENSURE

State Of*

County Of*

I ,*

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;

3. I am currently licensed to practice optometry in the State of*

under license number*

which was originally issued on*

4. I have been actively engaged in the practice of optometry for the past five (5) years;

5. I have had no adverse actions 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; and

7. I have not been held criminally liable for malpractice in the District of Columbia or any state or territory of the United States.

*

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*

Application/Examination fee

Price: $250.00

Processing Fee

Price: $5.00

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

JCB

Maestro

Card Number Expiration Date Security Code Cardholder Name

NOTE: To avoid the processing fee, 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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All information is Protected and secured.

*

I have read all questions, answers and statements and know the contents thereof. I hereby certify, under penalty of perjury, that the information furnished on this application are true, accurate and correct.

Board of Optometry

APPLICATION FOR LICENSURE AS A DOCTOR BY ENDORSEMENT AS PROVIDED BY CHAPTER 636 OF THE NEVADA REVISED STATUTES

IMPORTANT NOTICE:

In addition, note the following:

Supporting Documentation and Fees:

PART I - Applicant’s Identifying Information

Contact Information

Citizenship

Military Service

PART II - Education Information

2. Post Secondary Education History:

Name of College/University

Dates of Attendance

Graduated

Degree/Major

PART III - Record of Licensure Information

Jurisdiction

License Number

Date of Issuance

Status

PART IV - Personal History Information

PART V - Work History/Practical Experience

PART VI - Child Support Information

PART VII - Certifying Statement

AFFIDAVIT IN SUPPORT OF APPLICATION FOR LICENSURE

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