Fictitious Name Application

(One application per location)

Available for download here

APPLICATION FOR CERTIFICATE OF REGISTRATION OF ASSUMED/FICTITIOUS NAME
Pursuant to the provisions of Chapter 636 of the Nevada Administrative Code, I ,*
,O.D., a duly licensed optometrist in the State of Nevada, License Number*
, hereby make application for a Certificate of Registration of*
, to be used as an assumed/fictitious name under which optometry will be practiced at the following address.*
Street Address City State ZIP Code
Select any that apply:
I have registered the fictitious name with
- - The Nevada Secretary of State.
- The Nevada Secretary of State.
- - The Nevada County in which it will offer services. You must attach proof of the registration(s) below.
- The Nevada County in which it will offer services.
  You must attach proof of the registration(s) below.
Attach Documents*
Drop files here or

Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 10 MB, Max. files: 20.
Maximum File Size limit 10 MB
The following is a list of the name and address of each person holding any ownership interest, regardless of size, in the business operating under the assumed or fictitious name at this location. If any owners of the business at this location are entities (such as corporations, companies, partnerships or trusts), I have provided a list of each of those entities’ owners in the ”Comments” section of this application.
Name
Address
Street Address City State ZIP Code
I understand if any of the above information changes, I must submit a new Application within five business days of any change, addition or deletion. Failure to do so may result in disciplinary action by the Board.
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
Credit Card Billing Address*
Street Address City State ZIP Code
Credit Card

American Express
Discover
MasterCard
Visa
JCB
Maestro
Supported Credit Cards: 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, with checks made 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.
Comments
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Fictitious Name Application

(One application per location)

Available for download here

APPLICATION FOR CERTIFICATE OF REGISTRATION OF ASSUMED/FICTITIOUS NAME

Privacy Policy