Instructions for Completing an Application for Licensure By An

Instructions for Completing an Application for Licensure By An Out of State Licensed Optometrist Your application and supporting documents will be used to determine your eligibility to be licensed without requiring additional national entry level examination. When the required documentation is received and eligibility confirmed you will be issued a license. Incomplete or outdated applications will be returned (B&P Code §1635.5(a)(1)). Use the following as a checklist for submitting a complete application: Include with Application: One color passport photo indicated on page 2. Please write your name on the back of the photo, and tape to the area Fee (Non-Refundable): Include with your application a $275 application fee. This fee is non-refundable. Please make the check or money order payable to the “Optometry Board”. Fingerprints: All applicants are required to furnish the Board a full set of fingerprints for the purpose of conducting criminal background checks. An applicant can be denied a license to practice optometry subject to California Business and Professions Code Section 480. There are two methods by which you can be fingerprinted. They are: Live Scan. Is available only in California, for either residents or visitors, and is far speedier. The live scan form is available on the Board’s web-site or you may call the Board and request a live scan form be sent to you. For information on live scan fingerprinting, please visit the California Department of Justice web-site at http://ag.ca.gov/. Click on “Fingerprint Submissions”. You will be charged a finger-print scanning fee along with an additional fee of $51.00 for the processing of your fingerprint report. Paper Fingerprint Card. If you live out of state, you may go to a law enforcement agency to have your fingerprints taken. Please call the Board and request a fingerprint card be sent to you. Return the card with your application along with a $51.00 non-refundable processing fee. An optometric license will not be issued until clearance has been received from the Department of Justice and the Federal Bureau of Investigation. Application Form – OLA-2 Item 1: Item 2 : Enter your name. This name will be shown on your license. Enter your address. If this address is not your principal place of practice, you must inform the Board of your principal place of practice before you begin practice. This address will appear on the Board’s web-site for consumer licensing information. Enter your date of birth. This information is mandatory and will be needed to issue a license. Enter your social security number. Enter the name of your optometry school and the date your degree was conferred. Enter the month and year you sat or will sit for the California Laws and Regulations Examination. 1 of 2 Item 3: Item 4: Item 5: Item 6: Item 7: Enter the name and date of the examination which satisfied the licensure requirement for the state in which you were initially licensed. NOTE! IF YOU PASSED PART III OF THE NBEO AFTER JANUARY 1, 2000, DO NOT COMPLETE THIS APPLICATION. YOU WILL NEED TO SUBMIT THE STANDARD APPLICATION (OLA-1) PLEASE CONTACT THE BOARD FOR INFORMATION. Item 8: List all states you are/were licensed and the license number issued to you. NOTE! A letter of good standing from each state board with which you are licensed must be sent directly to the California Board. Item 9: If you answered “Yes” to this question, you must give a full and detailed explanation, including any and all charge/s, place of suspension or revocation, and the final outcome. Please use a separate piece of paper and attach to this application. Item 10: If you answered “Yes” to this question, you must give a full and detailed explanation, including any and all charge/s, place of conviction, and the final outcome. Please use a separate piece of paper and attach to this application. Item 11: You must fill out the “Certification of 5,000 Practice Hours” form (LBC-4) to show proof that you have been in active practice in a state in which you are licensed in five of the seven consecutive years Immediately preceding the date of this application. Fill out the form and submit along with the application. NOTE. Out of State licensed optometrists displaced due to a federally declared emergency may qualify for licensure with less than 5,000 hours if a sufficient period in active practice can be verified by the Board and all other requirements are met. For information on licensing procedures, please contact the Board. Item 12: The law requires that an applicant must meet TPA certification requirements as a condition of licensure by endorsement. Requirements are found in California Business and Professions Code §3041, and California Code of Regulations §1568. For your convenience, the requirements are summarized in the Board’s TPA fact sheet. To show proof that you met the California requirements for certification, you must request that a school or schools provide Certified documentation that you completed the educational or training requirements for certification. For proof of the TMOD requirement, you must request that the National Board of Examiners in Optometry (NBEO) sent a transcript of your score directly to the California Board. Item 13: Indicate whether you have met the required minimum continuing education requirements for the current and preceding year. If you marked “Yes”, you must submit original certificates of completion substantiating that you met the required 50 hours of Board approved continuing education. The requirements are listed below: Licensed Optometrist (TPA Certified): 50 hours of Board approved continuing education, 35 of which must be in the diagnosis, treatment and management of ocular disease in any combination of the following areas: • • • • • Item 14: Glaucoma, ocular infection, Inflammation, Topical steroids, Systemic medication, or Pain medication Declaration: Date and sign. 2 of 2 STATE AND CONSUMER SERVICES AGENCY Arnold Schwarzenegger, Governor BOARD OF OPTOMETRY 2420 Del Paso Road, Suite 255, Sacramento, California, 95834 TELEPHONE: (916) 575-7170 / (866) 585-2666 www.optometry.ca.gov APPLICATION FOR LICENSURE BY AN OUT OF STATE LICENSED OPTOMETRIST The following information is required under Sections 3044, 3045 & 3046 of the Business APPLICATION FEE: $275.00 and Professions Code. All terms of information requested are mandatory. Failure to provide Receipt Number : ______________ any of the requested information will result in the application being rejected as incomplete. The information provided will be used to determine qualification for licensure. The official ATS Number : ______________ responsible for the maintenance of this information is the Executive Officer. The information may be transferred to other interagency or intergovernmental agency, and/or FOR OFFICE USE ONLY enforcement agencies. Each individual has the right to review the files or records maintained on them by the agency, unless the records are identified as exempt from access All applicants are subject to fingerprinting for criminal background checks. If you are having your prints taken in California, you must use a Live scan form. You can download this form from the Board’s web-site or you can request this form by checking the box titled “Live Scan Form”. If you are having your prints taken outside of California, you must use a fingerprint card. If you need a fingerprint card, please mark the box titled “Fingerprint Card”. Live Scan Form (California Only) Fingerprint Card (Out of State) PLEASE TYPE OR PRINT LEGIBLY 1. Name: (FIRST) 2. Address: (NUMBER & STREET) (CITY) (STATE) (ZIP) (TELEPHONE) (MIDDLE) (LAST) 3. Date of Birth: (Mandatory) ___________________ mm / dd / yyyy 4. Section 30 of the Business and Professions Code and Public Law 94-455 (42 USCA 405 (c)(2)(C) authorize collection of your SSN. Your SSN will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgement or order for family support in accordance with Section 11350.6 of the Welfare and Institutions Code, or for verification of licensure or examination status by a licensing or examination entity that utilizes a national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your SSN, you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you. - (Mandatory) 5. Education: Name(s) of School(s) or College(s) of Optometry attended (NAME OF SCHOOL) (DATE ENTERED) (DATE DEGREE CONFERRED) 6. Have you sat for the California Laws and Regulations Examination? If yes, please provide the month and year of test administration. ___________ mm ________ yyyy Yes No OLA-2 (11/07) 1 of 2 7. Please list the name, month and year of the examination administered to qualify you for licensure: ___________________________________________ Name of Examination _______________ mm/yyyy 8. Please list all states in which you are licensed to practice optometry: State: _____________________ Lic. No.: ________________ ; State: _____________________ Lic. No.: ________________ ; State: ____________________ State: ____________________ Lic. No.: ________________ Lic. No.: ________________ NOTE: A LETTER OF GOOD STANDING MUST BE SENT FROM EACH STATE BOARD IN WITH WHICH YOU ARE LICENSED DIRECTLY TO THE CALIFORNIA BOARD. 9. Please indicate if you have ever had a license to practice optometry denied, suspended, or subject to disciplinary action Yes No (If you marked “Yes, provide full details including charge(s), where (state or territory) and final Disposition on separate piece of paper and attach to this application.) 10. Please indicate if you, as a juvenile or adult, have ever been convicted of or plead nolo contendere to any violation of a U.S. statute, state statute or local ordinance, other than vehicle code offenses in which fines levied were less than $50.00 (Convictions dismissed pursuant to Section 1203.4 of the Penal Code must be disclosed) Yes No (If you marked “Yes”, provide the full details of each offense, including nature, location and date of final disposition. Submit on a separate piece of paper with this application. 111. Please indicate whether you have met the 5,000 hours of practice requirement set forth in section 3057 of the California Business and Professions Code in five of the seven consecutive years preceding the date of this application. Yes No (If “Yes”, you must fill out the Certification of 5,000 Practice Hours form (LBC-4) and submit along with this application) (If you marked “Yes”, please refer to page two of the instructions for submitting documentation.) 112. Please indicate whether you have met TPA requirements set forth in section 3041.3 of the California Business and Professions Code. Yes No 13. Please indicate whether you have met the minimum continuing education requirements set forth in section 3059 of the California Business and Professions Code for the current and preceding year. Yes No (If you marked “Yes”, please refer to page two of the instructions for submitting documentation.) 14. I declare under penalty of perjury under the laws of the State of California that the answers and information given by me in completing this application, and any attached sheets, are true and I understand and agree that any misstatements of material facts herein may be cause for the denial of this application or for subsequent suspension or revocation of a certificate of registration to practice optometry in California if one is granted to me. I further declare that my signature on this application authorizes the National Practitioner Data Bank, the Federal Drug Enforcement Agency, and any other law enforcement agency or jurisdictional entity to release any and all information required by the California Board of Optometry. Signature of Applicant: ________________________________________ Date: _______________ PHOTOS MUST HAVE BEEN TAKEN WITHIN THE LAST SIX MONTHS USE TAPE DO NOT STAPLE ATTACH 2” x 2” PHOTOGRAPH HERE OLA-2 (11/07) 2 of 2 STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY ARNOLD SCHWARZENEGGER, Governor BOARD OF OPTOMETRY 2420 Del Paso Road, Suite 255, Sacramento, CA 95834 TELEPHONE: (916) 575-7170 FAX: (916) 575-7292 www.optometry.ca.gov CERTIFICATION OF 5,000 PRACTICE HOURS If you practiced at numerous locations during the time period being documented, use a separate form for each practice location. This certification is for use in establishing eligibility to become licensed in California based upon number of hours practiced and must accompany the Application for Licensure By An Out of State Licensed Optometrist. 1. Name: (First) (Middle) (Last) 2. Address: (Number & Street) (City) (State) (Zip) (Telephone) Were you self-employed ? Yes No • If you answered “No” proceed to Section I and have the employer or custodian of records* complete and certify the information. • If you answered “Yes”, go to Section II ___________________________________________________________________________________________________________________________________________________________________________________ □ □ SECTION - I Practice address during the period indicated below: (Number & Street) (City) From: (mm/dd/yyyy) (State) To: (mm/dd/yyyy) (Zip) (Telephone) Total hours Business name and address, if different from the practice address. (Name of business) (Number & Street) (City) (State) (Zip) (Telephone) LBC-4 2/07 1 of 2 SECTION - I (continued) Employer/Custodian of Records: I certify under penalty of perjury under the laws of the State of California that I am the custodian of records of the business listed above, and that the above is a true and correct representation of the records of the business. _________________________________ Printed/Typed Name of Certifying Person _________________________________ Signature of Certifying Person __________________________ (________)______________________ Date of Signing Telephone Number _________________________________________________________________________________________________ SECTION - II Dates and hours of practice. NOTE! IF THIS APPLICATION IS BEING MADE PURSUANT TO A FEDERALLY DECLARED EMERGENCY AS STATED IN BUSINESS AND PROFESSIONS CODE SECTION 3056, PLEASE INDICATE BELOW: □ □ From: (mm/dd/yyyy) From: (mm/dd/yyyy) From: (mm/dd/yyyy) YES (If yes, please call the Board at (866-585-2666 for information) NO (If no, please continue) To: (mm/dd/yyyy) To: (mm/dd/yyyy) To: (mm/dd/yyyy) Total hours: Total hours: Total hours: State and License Number: State and License Number: State and License Number: I declare under penalty of perjury under the laws of the State of California that the answers given by me, employer, or custodian of record in completing this application are true and I understand and agree that any misstatements of facts herein may be cause for the denial of my application for licensure t or for subsequent suspension or revocation of a certificate of registration to practice optometry in California if one is granted to me. _________________________________ Signature of Applicant __________________ Date *THE CUSTODIAN OF RECORDS is a person or institution that has charge or custody of documents, papers, or other valuables. LBC-4 2/07 2 of 2