Free 45276.FH11 - Indiana

APPLICATION FOR OPTOMETRIC LEGEND DRUG CERTIFICATE
State Form 45276 (R4 / 1-06) Approved by State Board of Accounts, 2006

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INDIANA OPTOMETRIC LEGEND DRUG PRESCRIPTION ADVISORY COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2057 E-mail: [email protected]

* Disclosure of your Social Security number is MANDATORY, according to IC 4-1-8-1 and this application cannot be processed without it. FOR OFFICE USE ONLY Date fee receipted (month, day, year)

Application fee

Receipt number

Certificate number

Date issued (month, day, year)

NOTICE: INSTRUCTIONS:
Name of applicant

Under IC 25-26-15, any licensed optometrist who administers therapeutic legend drugs, dispenses legend drugs, or prescribes legend drugs must be certified by the Indiana Board of Pharmacy. Please complete the following information and supply supporting documentation to begin the certificate process.
Social Security number * Telephone number ( )

Business name of applicant (if applicable)

County

Indiana practice address (number and street)

Date of birth (month, day, year)

City, state and ZIP code

Email address

Indiana Optometry license number

Has any previous license or certificate held by the applicant been surrendered, revoked, denied, or is pending action? (if Yes, please provide details)

Yes

No

To become certified, you must complete the following and provide documentation: 1. Provide proof of education in ocular pharmacology from a school or college of optometry or medicine approved by the Indiana Optometry Board by providing a transcript of your course work from the institution; and, 2 . Provide a photocopy of either a score report or a certificate proving successful completion of the Treatment and Management of Ocular Disease (TMOD) examination that is administered by the National Board of Examiners in Optometry.

I hereby apply for an Indiana Optometric Legend Drug Certificate in accordance with IC 25-26-15. I certify I have answered all questions to the best of my knowledge.
Signature of applicant Date signed (month, day, year)