Certificate of Ownership

CERTIFICATE OF OWNERSHIP

ARKANSAS STATE BOARD OF DISPENSING OPTICIANS

POST OFFICE BOX 627

HELENA, ARKANSAS 72342

870-572-2847

Ark. Code Ann. § 17-89-404 (d) requires - Each optical dispensary in the State of Arkansas whose title does not contain the proper name of an Arkansas optometrist or Arkansas physician skilled in diseases of the eye or a licensed or registered dispensing optician holding a certificate of licensure or registry in the State of Arkansas must file a certificate of ownership each year with the Arkansas Board of Dispensing Opticians between June 1 and June 30. Each certificate of ownership must give the name and address of the dispensary, the optometrist or physician skilled in diseases of the eye, or licensed or registered dispensing optician or person who owns or maintains legal responsibility of the dispensary.

If the OWNER’S NAME IS NOT IN THE TITLE OF THE OPTICAL DISPENSARY, please fill out the form and return to the state board office no later than June 30th.

Name of Optical Dispensary _______________________________________________

Business Address ________________________________________________________

City ___________________________________________________________________

State _________________________________ Zip _____________________________

Business Phone Number __________________________________________________

Name of Owner _________________________________________________________

(First) (Middle) (Last)

__ Ophthalmologist __ Optometrist __Licensed or Register Dispensing Optician

Owner’s Address ________________________________________________________

City _____________________________ State _________________ Zip ___________

Owner Phone Number ____________________________________________________

I own and maintain legal responsibility for this dispensary.

________________________________ _____________________

(Signature of Owner) (Date)