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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From
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To
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From
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To
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 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.”
Price: $543.75
Price: $0.00
$0.00
Date Format: MM slash DD slash YYYY
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.
Maximum File Size limit 10 MB
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