Biennial License Renewal 2022-2024 - Nevada State Board of Optometry

NEVADA STATE BOARD OF OPTOMETRY

Post Office Box 1824
Carson City, Nevada 89702
Telephone: (775) 883-8367
Facsimile: (775)305-0105
E-Mail: admin@nvoptometry.org

OPTOMETRY LICENSE RENEWAL APPLICATION

To submit this application by mail, Click here to download and print this form

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By my signature at the conclusion of this application to renew my license to practice optometry in the State of Nevada, I,*

License Number*

1. Are you currently obligated by Court Order for the payment of child support?*

Yes
No

2. Are you currently in your obligations under any Court ordered child support?

Yes
No

3. During the current licensing period, has the DEA or the federal government disciplined you, taken any action on your prescribing privileges, or have you voluntarily surrendered your DEA number, allowed it to lapse, or had a limited certificate issued?

Yes
No
N/A

4. Has any licensing jurisdiction, DEA or a state drug enforcement authority ever imposed discipline on you or limited your ability to prescribe?*

Yes
No
N/A

5. If you answered Yes to Question #4, when and where?*

6. Do you hold a Nevada OPAC?*

Yes
No

7. Have you registered for a Nevada PMP Account?*

Yes
No
N/A

8. Do you confirm all PMP entries attributed to your prescriptions at least every six months?*

Yes
No
N/A

9. My DEA# is:

10. My CS# is:

11. Have you been convicted of any drug or alcohol related offense within the current licensing period?*

Yes
No

12. If you answered Yes to Question #11, when and where?*

13. Has the State of Nevada or any jurisdiction issued you a business license to offer optometric services?*

Yes
No

14. If you answered Yes to Question #13, my business license number is:*

15. The business license is held under what name(s)?*

16. Have you ever served in the Military?*

Yes
No

18. 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

Other*

19. Has your spouse ever served in the Military?*

Yes
No

21. 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?*

21. 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

22. 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?*

22. 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

23. 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?*

23. 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

Preferred Board Communication Mailing Address*

Street Address City State ZIP Code

Public Mailing Address*

Street Address City State ZIP Code

Email*

Phone*

Choose From Below Options*

I wish to RENEW AN INACTIVE LICENSE ($500.00 for 2-year license)
I wish to RENEW AN ACTIVE LICENSE ($750.00 for 2-year license and one practice location)

RENEW AN ACTIVE LICENSE

Choose one:

I wish to have a substitute optometry certificate rather than a practice location.
Primary practice location address

Primary practice location address*

Street Address City State ZIP Code

Phone*

I have included $200.00 to renew each practice location listed below for the upcoming 2-year licensing period.

I have included $200.00 to renew each practice location listed below for the upcoming 2-year licensing period.

Additional practices : If you have a primary practice location, but wish to also hold a substitute optometrist certificate, enter "substitute" in the field provided for Address below. If you merely have additional practice locations, add each of them below by clicking the "

".

Additional practice : If you have a primary practice location, but wish to also hold a substitute optometrist certificate, enter "substitute" in the field provided for Address below. If you merely have additional practice locations, add each of them below by clicking the "+".*

Address, City, Zip	Phone	Fax

Active license renewal fee

Price:

Additional practice locations fee

Price: $200.00

RENEW AN INACTIVE LICENSE

I am not currently practicing optometry in the State of Nevada. If I wish to practice in Nevada at any time during the renewal period, I recognize that I must provide the Board prior written notice of the date and location I will be practicing and submit an additional $250.00 to activate my license.

Name*

First

License Number*

Mailing Address*

Street Address City State ZIP Code

Email*

Phone

Inactive license renewal fee

Price:

Penalty Fee

Price:

Total

$0.00

Total

$0.00

By submitting this information and checking this box, I affirm that each document related to this application for renewal 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 optometrist licensed by the Nevada Board of Optometry, am fully responsible for the content of the submission. My CE, as required by Board Policy #5, has already been submitted to the Board or is being submitted with this application.*

By submitting this information and checking this box, I affirm that each document related to this application for renewal 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 optometrist licensed by the Nevada Board of Optometry, am fully responsible for the content of the submission. My CE, as required by Board Policy #5, has already been submitted to the Board or is being submitted with this application.

I authorize the preceding sum to be charged to my credit card to the account of the Nevada State Board of Optometry.*

I authorize the preceding sum to be charged to my credit card to the account of the Nevada State Board of Optometry.

Name*

First

Date*

Billing Address*

Street Address City State ZIP Code

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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