Fictitious Name/Change of Ownership - Nevada State Board of Optometry

(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*

Email

, 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.*

Address City State ZIP Code

The listed person/entity’s percentage of ownership is

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.

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

If the above listed ownership percentage is 100%, proceed to the attestation and credit card billing portion of this form.

If the above listed ownership percentage is anything less than 100%, the following is a list of the name and address of each person holding any ownership interest, and percentage of the optometry practice that he or she owns 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

Address City State ZIP Code

The listed person/entity’s percentage of ownership is

Additional owner(s): If this business operating under the assumed or fictitious name at this location has additional owners, add each of them below by clicking the

Additional owner(s): If this business operating under the assumed or fictitious name at this location has additional owners, add each of them below by clicking the

Additional owner(s) List

Name	Address	City	State	ZIP Code	The listed person/entity’s percentage of ownership is

I understand if any of the above information changes, I must submit a new Application not later than 90 calendar 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 I have conferred with each above listed owner and who have agreed with the above listed information regarding all persons or entities holding any ownership interest and the percentages of such ownership.

Name*

First

Date*

Credit Card Billing Address

Street Address City State ZIP Code

Credit 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.

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