Request for Additional Practice Location

NEVADA STATE BOARD OF OPTOMETRY
- Post Office Box 1824
- Carson City, Nevada 89702
- Telephone: (775) 883-8367
- Facsimile: (775)305-0105
- E-Mail: admin@nvoptometry.org
Request for Additional Practice Location/Duplicate Certificate
Name*
First
License #*
With this new location, I will be practicing in the following total number of locations.
Start Date
MM slash DD slash YYYY
Address Certificate will be displayed
Street Address City State ZIP Code
Is this now your primary location?
- Yes
- No
Where would you like the certificate to be mailed?
Street Address City State ZIP Code
Attach Additional Location Information if Needed
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
Additional Location/Duplicate Certificate Fee*
Price: $200.00
PLEASE ENTER THE NUMERAL "1" HERE. You must complete one form for each new location
Paying online? The Optometry Board accepts Visa. Mastercard and American Express via its website at www.nvoptometry.org. If paying by mail, please make all checks to the Nevada State Board of Optometry and mail them to P.O. Box 1824, Carson City, NV 89702.

Please allow 30 days to receive a renewal/new location card from the board. Your renewal/location card must be displayed with your Certificate. Duplicate License Certificates may require up to 60 days.
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 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.
Name*
First
Date*
MM slash DD slash YYYY
Billing Address*
Street Address City State ZIP Code
Credit Card

American Express
Discover
MasterCard
Visa
JCB
Maestro
Supported Credit Cards: American Express, Discover, MasterCard, Visa, JCB, Maestro
Card Number Expiration Date Security Code Cardholder Name
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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Request for Additional Practice Location

NEVADA STATE BOARD OF OPTOMETRY

Request for Additional Practice Location/Duplicate Certificate

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