ARKANSAS STATE BOARD OF OPTOMETRY
2018 RENEWAL APPLICATION FOR CERTIFICATION AS AN OPTOMETRIC PHYSICIAN
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PAYABLE TO: ARKANSAS STATE BOARD OF OPTOMETRY Board Address:
Required Fee: $ 50.00 (Check or Money Order) P O Box 512
Due: February 1, 2018 Searcy, AR 72145
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Name______________________________________
Mailing Address________________________
Mail City____________________________________, State_____ Zip_____________________ SOC SEC#
MAKE CORRECTION ON MAILING ADDRESS IF NECESSARY
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FEDERAL DEA #_ LICENSE #:
HOME PHONE: OFFICE PHONE:
OPT PHYSICIAN # FAX PHONE:
PRIMARY OFFICE ADDRESS:
STREET: CITY:
OFFICE ZIPCODE: BRANCH OFFICE ZIPCODE
IF THE ABOVE IS BLANK OR INCORRECT, PLEASE COMPLETE OR CORRECT.
THE DEA REQUIRES A STREET ADDRESS FOR YOUR PRACTICE LOCATION.
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DO YOU WORK IN A BRANCH OFFICE?________________
IF YES, PLEASE LIST ADDRESS BELOW.
STREET:_____________________________________________
CITY:_________________________________STATE:________ZIP:________________
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For renewal, you need to provide the following information to the Board:
_______1. Current C P R card or letter from the instructor.
_______2. Include a fee of $50.00
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O.E. TRACKER #«OEnumber»
I verify that the above information is correct, and that I have received at least twelve (12) hours of continuing education for license renewal and an additional eight (8) hours for certification as an optometric physician for a total of at least twenty (20) hours during the calendar year 2017.
E-Mail Address:____________________
Date:______________________________Signature:___________________________________