CE Summary Form

SUMMARY OF CONTINUING EDUCATION INFORMATION

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I,*
,O.D. ,License Number*
hereby submit copies of documents reflecting attendance at, or completion of pre-approved continuing education courses taken between March 1,
and February 28,
which fulfill the continuing education requirements for renewal for the
license year pursuant to NRS 636.260
I have completed this many hours of approved TPA continuing education
I have completed this many hours of general optometric continuing education, including practice management
I have a DEA number and CS number, and have completed this many hours of substance/opioid abuse related continuing education
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Name*
First Last
*
- 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 a 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.
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