Fictitious Name Application

  • APPLICATION FOR CERTIFICATE OF REGISTRATION OF ASSUMED/FICTITIOUS NAME

  • [Insert name of local business licensing entity] verifying its approval for the use of the assumed/trade name.
  • The assumed/trade name will be used at the following practice location[s]:
  • I understand if I change, add to, or delete any of the above location[s], I must notify the Board in writing prior to any such change, addition or deletion. Failure to do so will result in possible disciplinary action by the Board.

  • Drop files here or
    Accepted file types: jpg, jpeg, png, doc, docx, pdf.
  • Price: $50.00
  • Price: $5.00
  • $0.00
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  • 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.
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