Application for License by Endorsement - Nevada State Board of Optometry

For 2-Year License

APPLICATION FOR LICENSURE AS AN OPTOMETRIST 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 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 records laws of the State of Nevada. Carefully follow the directions on this application form.

In addition, note the following:

The application must be submitted with the required documents and the required fees. These fees are not refundable.
Disclosure of your Social Security Number is mandatory pursuant to NRS 636.157; and
If the name shown on your supporting documents is different from that on your application, you must submit proof of a legal name change in the form of a marriage license, divorce decree, affidavit or court order.

You must provide the following supporting documentation and fees:

$75 application fee plus $375.00 licensure by endorsement fee.
Wallet or passport size colored photo taken within six months of the submission of this application.
A letter of Good Standing or electronic verification of your current licensure status including date of issuance and disciplinary record from each state in which you are, or have been, licensed.
Online State Law Exam completion with a passing score. Nevada’s exam is administered by NBEO at https://www.optometry.org/law.cfm#

Your application is NOT complete until the Board receives this application and all supporting documents and required fees.

PART I - Applicant’s Identifying Information

Provide all requested information. You must notify the Board of Optometry, in writing, of any changes that occur after you file the application particularly email and mailing address changes.

Name*

Last Name

First Name*

First Name

MI

Suffix, if any

Social Security Number*

Current Mailing Address*

Street Address City State ZIP Code

Permanent Mailing Address

Street Address City State ZIP Code

Identify Preferred Mailing Address*

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

Current
Permanent

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

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

Date of Birth*

Contact Information

Home Phone*

Cell Phone

E-Mail Address (The Board communicates primarily via E-Mail.)*

Citizenship

Are you a citizen of the United States?*

Yes
No

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

Yes
No
N/A

U.S. military

Have you ever served in the US military?*

Yes
No

If “Yes,” please provide date(s) of service:*

From

To*

To

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

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

Military Occupation Specialty/Specialties?

Has your spouse ever served in the US military?*

Yes
No

If “Yes,” please provide date(s) of service:*

From

To*

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?

Have you ever served on active duty in the Armed Forces of the United States and separated from such service under conditions other than dishonorable?

Yes
No

Have you ever been assigned to duty for a minimum of 6 continuous years in the National Guard or a reserve component of the Armed Forces of the United States and separated from such service under conditions other than dishonorable?

Yes
No

Have you ever served the Commissioned Corps of the United States Public Health Service or the Commissioned Corps of the National Oceanic and Atmospheric Administration of the United States in the capacity of a commissioned officer while on active duty in defense of the United States and separated from such service under conditions other than dishonorable?

Yes
No

PART II - Education Information

2. Post Secondary Education History:

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

Name of College/University

Dates of Attendance

From - To

Graduated

2

Yes
No

2

Yes
No

2

Yes
No

2

Yes
No

Degree/Major

2

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 may result in denial of your application, or other appropriate action.

Jurisdiction

License Number

Date of Issuance

Status

If you need additional room, add information under “Comments” at the end of this application.

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 are there any unresolved or pending complaints filed against you by any optometric licensing authority?*

Yes
No

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

Yes
No

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

Yes
No

14. Has your application for DEA certification ever been denied?*

Yes
No
N/A

15. Has the DEA ever disciplined your certification, or have you ever voluntarily surrendered a DEA certification, 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, federal drug enforcement agency, or 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 criminal offense in any state or federal court (other than minor traffic violations) regardless whether a sentence was imposed ?*

Yes
No

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

Yes
No

19. Have you ever had a felony or criminal conviction expunged?*

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 a sentence was imposed?*

Yes
No

21. In the last 5 years, have you 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

2

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

2

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

2

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

2

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, you must certify Under penalty of perjury:

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

Yes
No

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

Yes
No

b. Currently, my child support obligation is in arrears.*

Yes
No

c. 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

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 herein are true, correct, and complete to the best of my knowledge, and 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 my electronic signature shall serve 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 (Legal Name),*

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 at least 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 by, nor am I currently under investigation by, the optometric regulatory authority of the District of Columbia or any state or territory in which I currently hold or have a 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.

Application/Examination fee

Price:

(includes $75 application fee and $375.00(includes remainder of 2-year licensing period and certificate)

Total

$0.00

By entering my name and the date below, 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 another person to complete or submit this information on my behalf, I, the applicant optometrist , am fully responsible for the content of the submission.

Name*

First

Date*

Billing Address*

Street Address City State ZIP Code

Credit Card Billing Address

American Express

Discover

MasterCard

Visa

JCB

Maestro

Card Number Expiration Date Security Code Name as it appears on the Card

NOTE: Payments may be made by mail, by 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.

Attach Photo

Accepted file types: jpeg, Max. file size: 10 MB.

Upload a recent, clearly recognizable passport-size photograph (2 x 2 inches) with a maximum file size of 10 MB

Hidden

CPR Card

Accepted file types: png, jpg, Max. file size: 10 MB.

Attach a copy of a current CPR card

Comments

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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 is true, accurate and correct.