Application for Licensure as a Nevada Optometrist - Nevada State Board of Optometry

APPLICATION FOR LICENSURE AS A DOCTOR OF OPTOMETRY BY EXAMINATION 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 information laws of the State of Nevada. Carefully follow the directions on this application form.

In addition, note the following:

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 shown on your application, you must submit proof of legal name change.

You must provide the following supporting documentation and fees:

Optometry school transcript sent directly from institution
Wallet or passport size colored photo taken within 30 days of the submission of this application

Quarter	Even Years	Odd Years
Quarterly Proration Schedule ($75 non-refundable application fee plus $93.75 for each calendar quarter remaining – Includes 2-year license at one practice location).
March 1 – May 31	$825.00	$450.00
June 1 – August 31	$731.25	$356.25
September 1 – November 30	$637.50	$262.50
December 1 – February 28 or 29	$543.75	$168.75

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

Name*

Last Name

First Name*

First Name

MI

Suffix

Social Security Number*

Current Mailing 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*

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 names or aliases 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 Numbers*

Cell Phone

E-Mail Address*

Citizenship

Are you a citizen of the United States?*

Yes
No

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 to perform labor as a healthcare worker, other than an optometrist?*

Yes
No
N/A

Military Service

Have you ever served in the Military?*

Yes
No

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

From

To*

To

Branches 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 Military?*

Yes
No

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

From

To*

To

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

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:

Name of College/University

Dates of Attendance

From - To

Graduated

to

Yes
No

to

Yes
No

to

Yes
No

to

Yes
No

Degree/Major

to

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 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 a 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 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 there is an arrearage on my child support obligation*

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 the photograph attached hereto is a true likeness of myself. I hereby authorize 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 my signature shall act as authorization of entities in possession of applicable information to release such information to the licensing authority.”

Application/Examination fee

Price:

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*

Billing Address*

Street Address City State ZIP Code

Credit Card

American Express

Discover

MasterCard

Visa

JCB

Maestro

Card Number Expiration Date Security Code Cardholder Name

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