Request for location change

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 Address/Location Change
Name*
First
License #*
Issue Date*
New Address*
Street Address City State ZIP Code
Is this now your primary location?*
- Yes
- No
Do you have a Nevada Optometry License Certificate to hang at this location?*
- No, I need to request a Duplicate Certificate.
- Yes, I am no longer practicing at
this location*
Attach Documents
Drop files here or

Accepted file types: jpg, jpeg, png, doc, docx, pdf.
Addr./Loc. Change Fee*
Fee: $25.00 At how many locations will you now be practicing?
Duplicate License Certificate
Fee: $200.00
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 up to 30 to receive your new location card from the board. Your location card must be displayed with your Certificate. If you are requesting a Duplicate Certificate please allow up to 60 days.
Processing Fee (3.5%)
Fee: $0.00
Processing Fee (3.5%)
Fee: $0.00
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*
Billing Address*
Street Address City State ZIP Code
Credit Card

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 location change

NEVADA STATE BOARD OF OPTOMETRY

Request for Address/Location Change

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