(One application per location)
APPLICATION FOR CERTIFICATE OF REGISTRATION OF
- Select any that apply:
I have registered the fictitious name with
- The Nevada County in which it will offer services.
You must attach proof of the registration(s) below.
Accepted file types: jpg, jpeg, png, doc, docx, pdf.
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.
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.
Date Format: MM slash DD slash YYYY
NOTE: To avoid the 3.5% credit card processing fee, 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.
All information is protected and secured.