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APPLICATION FOR OPTOMETRY LICENSE
State Form 7 (R10 / 2-06) Approved by State Board of Accounts, 2006

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INDIANA OPTOMETRY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2054 E-mail: [email protected]

*Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER LICENSE ISSUANCE DATE (month,day,year)
DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY
PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS. Name of applicant (last, first, middle, maiden) Address (number and street or rural route) State E-mail address ZIP code Date of birth (month, day, year) APPLICANT INFORMATION

APPLICANT Attach one (1) passport-quality photograph taken not earlier than one (1) year prior to the date of application, dated and signed on the back. In the applicants handwriting, put I certify that this is a true photograph of me.

Social Security number* City Telephone number (daytime)

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Place of birth (city and state or country)

BASIS FOR LICENSURE

Application for licensure by: (Please check appropriate box.) EXAMINATION
OPTOMETRY SCHOOL OF GRADUATION

ENDORSEMENT

Name of school

Location

Date of graduation

EXAMINATION RECORD NATIONAL BOARD OF EXAMINERS IN OPTOMETRY National Boards Date of most recent test (month, day, year) Where taken (state) How many times

Part I Part II Part III TMOD ANY OTHER NBEO EXAMINATION TAKEN?
STATE BOARD EXAMINATION If you are applying by endorsement and have not taken Part III of the National Board of Examiners in Optometry (NBEO), please list the State Board Examination you will be endorsing to the State of Indiana. State Examination date License current? Yes
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No

PRE-PROFESSIONAL EDUCATION Name of school Location From (month, year) To (month, year) Degree

PROFESSIONAL EDUCATION (SCHOOL OF OPTOMETRY) Name of school Location From (month, year) To (month, year) Degree

Original state of licensure

STATES OF LICENSURE License number

List all states (including Indiana) in which you have been licensed or certified to practice optometry. State License number Date issued Date expires Issued by examination or endorsement

WHERE YOU HAVE LIVED List all the places you have lived since graduation from Optometry School. General Location Dates

WHERE YOU HAVE BEEN EMPLOYED List all the places you have been employed since graduation from Optometry School. Name and address of employer Responsibilities Dates

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STATEMENTS

If your answer is YES to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. If malpractice, provide name(s) of plaintiff(s). Letter(s) from attorney(s) or insurance company(s) are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Have you ever previously filed an application in the State of Indiana? 2. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice optometry or any regulated health occupation in any state (including Indiana) or country? 4. Are you now being, or have you ever been, treated for drug or alcohol abuse? 5. Have you ever been convicted of, plead guilty or nolo contendre to: A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.) 6. Have you ever had a malpractice judgment against you or settled any malpractice action?
APPLICATION AFFIRMATION

YES

NO

YES

NO

YES YES

NO NO

YES

NO

YES YES

NO NO

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct. Signature of applicant Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Indiana Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing any application for optometry licensure. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Indiana Professional Licensing Agency to disclose to the aforementioned organizations, persons and institutions any information which is material to my application, and I hereby specifically release the Agency and Board from any and all liability in connection with such disclosure. A photostatic copy of the authorization has the same force and effect as the original.
AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same. Signature of applicant

Date signed (month, day, year)

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VERIFICATION OF OPTOMETRIST STATE LICENSURE
Part of State Form 7 (R10 / 2-06)

Please return to: INDIANA OPTOMETRY BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2054 E-mail: [email protected]

*Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. INSTRUCTIONS: 1. Complete this form. 2. Make copies to send to each state in which you hold or have held a license. 3. Request the state(s) to complete and send directly to the address on the upper right. 4. If you are applying for licensure by endorsement based upon a state constructed examination, the state board must complete the Endorsement Criteria section on the back of the verification form. PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS. Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) State License number ZIP code Date of issue (month, day, year) APPLICANT INFORMATION Social Security number*

I hereby authorize the state of ____________________________________ to furnish the Indiana Professional Licensing Agency with the information below. Signature of applicant Date signed (month, day, year)

License number

LICENSE INFORMATION Date issued (month, day, year)

Expiration date (month, day, year)

Has the license been subject to disciplinary action? Yes No (If yes, please attach copies of any disciplinary action taken by your board.) LICENSED BY Examination Endorsement Other

Licensed by National Board of Examiners in Optometry: Part I Part II Part III TMOD State Constructed Examination administered? Date of examination (month, day, year) Yes Name Title State Board Date (month, day, year) No

Please Affix Board Seal

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ENDORSEMENT CRITERIA

If you are applying for an optometry license based upon a state constructed examination, the state board must complete this section of the form. In order to qualify for an Indiana license, the applicant must have attained an average score of 75, with no score below 65, on a hands-on clinical skills examination equivalent to Indiana examination. In order to assist the board with its evaluation, please indicate whether the applicant was required to pass a hands-on clinical test in the following areas and the applicants score on each test. NOTE: This information is not required if the applicant has passed Part III of the NBEO examination. 1. Determining refractive status (e.g. retinoscopy, subjective refraction) 2. Contact lens fitting (e.g. insertion, removal, fit evaluation) 3. Internal eye health evaluation other than direct ophthalmoscopy (e.g. monocular indirect, binocular indirect, gonioscopy, contact or non-contact fundus lens) 4. Neurological evaluation (e.g. fields, pupils, Amsler grid, confrontation) 5. External eye health (e.g. slit lamp, ocular motility, foreign body removal) 6. Binocular function (e.g. cover test, Worth Four-Dot, Bagolini lenses, Keystone skills) 7. Case history 8. Ophthalmic materials (e.g. lens designs, verification, adjustment) 9. Tonometry 10. Low vision Score _____________ Score _____________ Hands-on Hands-on

Score _____________ Score _____________ Score _____________ Score _____________ Score _____________ Score _____________ Score _____________ Score _____________

Hands-on Hands-on Hands-on Hands-on Hands-on Hands-on Hands-on Hands-on