Application for Certificate to practice as a SUBSTITUTE OPTOMETRIST

pursuant to NAC 636

I,*
, Nevada Optometry License No.*
, intend to offer my services as a substitute optometrist at one or more fixed optometric practices to relieve existing practicing optometrists.

If I substitute in a single practice location or substitute for a single optometrist for more than 28 cumulative days during the current licensure period, I understand that I must declare that site as a secondary practice location and register the same with the Board.

I recognize that I must keep a written log of each date and location where I offer substitute optometric services, and the name of each optometrist for whom I substitute. I agree to provide a copy of the log to the Board office quarterly, via email.
Mailing Address*
Mailing Address City State ZIP Code
Email*
Phone*
Application 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 another 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 this submission.
Name*
First
Date*
MM slash DD slash YYYY
Billing Address*
Street Address City State ZIP Code
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Name as it appears on card
NOTE: Payment may be made by mail, with checks 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 payment has been received.
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Application for Certificate to practice as a SUBSTITUTE OPTOMETRIST

pursuant to NAC 636

NOTE: Payment may be made by mail, with checks 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 payment has been received.

Privacy Policy