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Form 08-4232d - Verification Of Education - Department Of Community And Economic Development

Department of Community and Economic Development

Division of Occupational Licensing

Board of Examiners in Optometry

P.O. Box 110806, Juneau, Alaska 99811-0806

(907) 465-2580

E-mail: license@dced.state.ak.us

VERIFICATION OF EDUCATION

(This form to be used only by applicants who have not yet completed a Doctorate of Optometry degree program.)

SECTION A. After completing Section A, submit this form to the registrar of the college or university where your degree is

being pursued.

TO BE COMPLETED BY THE APPLICANT (Please type or print legibly):

Last Name

First Name

Middle Name

Maiden Name

Mailing Address

City

State

ZIP Code

(

)

Daytime Telephone Number

Date of Birth

I hereby request and authorize the

to provide any and all

pertinent information requested in this form to the Alaska State Board of Examiners in Optometry to complete an application

filed with that agency.

Applicant Signature

Date Signed

All optometry examination applicants who have not yet completed an optometry degree program must verify that they are in

their final semester. The following information must be officially verified by the college or university where your degree is being

pursued.

SECTION B

TO BE COMPLETED AND MAILED BY REGISTRAR OF COLLEGE OR UNIVERSITY

I hereby certify that

matriculated in the

(Applicant)

on the

day of

has

(Name of College or University)

obtained senior status and is actively pursuing completion of her/his final semester toward completion of a Doctorate of

Optometry degree.

Expected graduation date

COMMENTS:

SEAL OF COLLEGE OR UNIVERSITY

Signature of Registrar

Date

Please return this form directly to the Alaska state board at the above address.

08-4232d (Rev. 1/00)

Form 08-4232d - Verification Of Education - Department Of Community And Economic Development

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