Form 08-4232b - Verification Of Licensure - State Of Alaska
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1State of Alaska
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 LICENSURE
APPLICANT: COMPLETE TOP HALF OF THIS FORM AND FORWARD IT TO THE OPTOMETRY BOARD(S) IN ALL
STATES WHERE YOU ARE LICENSED.
I am applying to the Alaska Board of Examiners in Optometry for a license to practice optometry. The board requires
certification of the status of my license in each jurisdiction in which I hold or have held licenses.
Last Name
First Name
Middle
Social Security Number
Mailing Address
License Number
City
State
ZIP Code
I hereby request and authorize the State of
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
TO STATE BOARD
Please complete the bottom half of this form and return it directly to the Alaska State Board of
Examiners in Optometry at the address listed above.
Licensing Jurisdiction
Name of Licensee
Licensed By (reciprocity, examination, etc.)
License Number
Original Issue Date
Expiration Date:
Periods of Lapse
Is licensee authorized to use pharmaceutical agents for diagnostic purposes (DPA)?
Yes
No
Is licensee authorized to prescribe pharmaceutical agents for therapeutic purposes (TPA)?
Yes
No
Has the license ever been revoked, suspended, placed on probation, or restricted in any way?
Yes
No
If yes, please enclose an explanation or documentation.
Has the licensee ever been the subject of an unresolved complaint, review procedure, or disciplinary action?
Yes
No
If yes, please enclose an explanation or documentation.
Comments
Name
Signed
SEAL
Title
Date
08-4232b (Rev. 1/00)
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