Name Change Request

I,*
, Nevada Optometry License No.*
Wish to change my name to, and to display on my optometry license certificate as:*
I would like my new optometry license certificate to be mailed to:*
I would like the new location card(s), Optometric Pharmaceutical Agent Certificate (OPAC), and Glaucoma certificate, if applicable to be emailed to:*
Please upload a copy of your legal name change document, court order granting petition for name change, or marriage license.*
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 20 MB, Max. files: 10.
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
Billing Address*
Street Address City State ZIP Code
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Name as it appears on card
NOTE: Payment may be made by mail, with checks 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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Name Change Request

NOTE: Payment may be made by mail, with checks 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.

Privacy Policy