New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Optometrists
124 Halsey Street, 6th Floor, P.O. Box 45012
Newark, New Jersey 07101
(973) 504-6440
How to Transfer your
Inactive-Paid License to an Active License
Send a written request to the:
New Jersey State Board of Optometrists
P.O. Box 45012
Newark, New Jersey 07101
You must submit this form as your written request for transfer of your inactive-paid Optometrist license. Upon receipt of this application
requesting the transfer of your licenses, you must submit the relevant information for your transfer.
Initial Optometrist Inactive-Paid transfer to Active Status: (For the transfer of the Inactive-Paid Optometrist license and issue
an initial OM-Certication) must send the following:
• Pay $ 150.00 if you are transferring your license from inactive-paid to active during the rst year of the biennial renewal period.
(Transferring between May 1st of every odd year through April 30th of every even year.)
• Pay $ 75.00 if you are transferring your license from inactive-paid to active during the second year of the biennial renewal
period. (Transferring between May 1st of every even year through February 20th of every odd year.)
Renewed Optometrist Inactive-Paid license transfer to Active Status: (For the transfer of BOTH Inactive-Paid Optometry
license and Inactive Certication) must send the above transfer fee and the following additional information:
• Notarized afdavit of employment indicating each job held during the period of suspension or inactive status which includes
the names, addresses, and telephone numbers of each employer. The letter should state whether or not you have been working
in NJ since license expired.
• Documented proof that you completed the 50 continuing education credits required for the previous biennial renewal period that
your license was expired.
• Payment of the $250.00 TPA/OM-Certication fee, and payment of the $18.75 resubmit of a criminal history background check
fee for a total required payment of $418.75.
• Completion of a certication and authorization form for criminal history background check. See the initial application for a
copy of this form.
• Verication of having or held a professional license or certication of any kind in New Jersey, any other state, the District of
Columbia or in any other jurisdiction. A verication should come directly from the State ofce. Please contact that state for their
procedures on how to complete a state license verication or a letter of good standing. (Do not send a copy of your license.)
Please complete this entire form and return to the above address.
1. Name: ___________________________________________________________________________________________________
Last name First name Middle initial
2. License number: 27OA ____________________________
3. Mailing address: ___________________________________________________________________________________________
Street address City State ZIP code
Check one: New address Same as application
4. Daytime telephone number: ______________________________ Home telephone number: ______________________________
(includeareacode) (includeareacode)
5. Cellphone number: ____________________________ E-mail address: _______________________________________________
(includeareacode)
6. Business address: __________________________________________________________________________________________
Street address City State ZIP code
Business telephone number: _____________________________
(includeareacode)
Business e-mail address: ____________________________________________________________________________________
7. Licensee working at this location: _____________________________________________________________________________
Licensee license number: 27OA00 _______________________00
