Request for location change - Nevada State Board of Optometry

NEVADA STATE BOARD OF OPTOMETRY

WILLIAM F.HARVEY, O.D.

Board President

CHEN K.YOUNG, O.D.

Board Member

Post Office Box 1824
Carson City, Nevada 89702
Telephone: (775) 883-8367
Facsimile: (775)305-0105
E-Mail: admin@nvoptometry.org

SHERESE SETTELMEYER

Public Board Member

MARIAH L. SMITH, O.D.

Board Member

CAREN C. JENKINS, ESQ.

Executive Director

cjenkins@nvoptometry.org

Request for Address/Location Change

Name*

First

License #*

Issue Date*

New Address*

Is this now your primary location?*

Yes
No

Do you have a Nevada Optometry License Certificate to hang at this location?*

Yes
No

Select Your Choice*

No, I need to request a Duplicate Certificate.
Yes, I am no longer practicing at

this location*

Attach Documents

Drop files here or

Addr./Loc. Change Fee*

Fee: $25.00 At how many locations will you now be practicing?

Duplicate License Certificate

Fee: $75.00

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.

*

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*

Processing Fee (3.5%)

Fee: $0.00

Processing Fee (3.5%)

Fee: $0.00

Total

$0.00

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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