Fillable Optometrist Application Instructions / Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Optometrist Application Instructions / Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 79 check-boxes
  • 143 other fields

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New Jersey Ofce 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
Optometrist
Application Instructions / Checklist
Use this checklist to determine whether you have complied with all of the requirements for licensure in New Jersey as an optometrist.
Once your application has been received, a le will be established and you will be notied regarding any missing documents or fees.
Application Fee: $125.00
Please enclose a nonrefundable check or money order in the amount of $125.00 made payable to the “New Jersey State Board
of Optometrists” and mail it with your application to: New Jersey State Board of Optometrists, P.O. Box 45012, Newark, NJ
07101.
Licensure Fee (Active Status or Inactive-Paid Status)
Answer all of the questions on each page of the application.
Attach a clear, full-face, passport-style photograph (2”x2”) of your head and shoulders, taken within the past six months, to the
front page of the application. Please sign and print your name along with the date on the back of the photo.
Enter your Social Security number.
All applicants who have had a name change due to naturalization, marriage, divorce or other decrees, must submit legal
documentation of their name change.
If you have taken the National Board of Examiners in Optometry (NBEO) Exams for Part I, Part II, Part III and the Treatment
and Management of Ocular Disease (TMOD) exam, please contact the NBEO to have your ofcial exam scores sent directly to
the Board. If you wish to request your exam scores in writing, the address is: National Board of Examiners in Optometry, 200
South College St., Suite 1920, Charlotte, North Carolina 28202, and their contact numbers are 704-332-9565 and 1-800-969-
3926. Also, you may contact them by e-mail at: nbeo@optometry.org.
If you have taken the North East Region Clinical Optometric Assessment Testing Service (NERCOATS) exam or any other
state’s clinical or written exam, you must contact the state board in the state where you took the exam and request that the board
send conrmation, on their letterhead, that you took and passed the exam, and also provide an outline of your ofcial test and
your scores, and send that information directly to the Board ofce at: New Jersey State Board of Optometry, P.O. Box 45012,
Newark, New Jersey 07101.
A verication letter from the optometry school must be mailed directly by the registrar of that accredited school of optometry
to the Board.
A verication letter from an optometry school which applies to any person who graduated prior to 1992 that will verify that his
or her therapeutic education is substantially equivalent to that of a graduate after 1992. If you completed a 30-hour or 100-hour
course in order to be qualied to take the TMOD examination, then please have your registrar mention this in your verication
letter. If you graduated after 1992, the verication letter is not required; your optometry school transcript is sufcient.
Applicants who are foreign educated must have a Credential Evaluation completed in the United States by one of the evaluation
services. They will determine if your education is substantially equivalent to that of a current graduate of an optometric school
in the U.S.
Send a current copy of CPR Certication. The Board curently accepts:
• American Heart Association
• The Red Cross
• Health and Safety Institute and Medic First
Be sure to download, complete and submit the Oral TPA application.
Verication of licensure - you must contact each state in which you hold (or have held) an optometry license (active, inactive
or expired) and request that each board mail a verication of your license directly to the: New Jersey State Board of Optometry,
P.O. Box 45012, Newark, NJ 07101. Please contact each state ofce to nd out about the required processing fees for verication
before mailing your request.
If you answered “Yes” to any of the child-support questions, you must provide a written explanation on a separate sheet of paper
and then attach it to the application.
All applicants must complete the “New Jersey Optometry Law Examination” and return it with your application for licensure.
Please download the New Jersey Optometry Law Examination from our website.
Fill out the Certication and Authorization form for a criminal history record background check and mail it with the application
to the Board.
Once the entire application has been completed and signed by you, have it signed and stamped/sealed by a notary public.
Notice
Any applicant ling an application after November 22, 2003, will be subject to a criminal history record background check pursuant to
P.L. 2002, chapter 104. Information regarding this background check will be provided to applicants.
New Jersey Ofce 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
Application for an Optometry License
Date : ____________________________
A nonrefundable application ling fee of $125.00, in the form of a check or money order made out to the State of New Jersey, must be
submitted with this application (applicants should understand that if the application ling fee is paid with a personal check, and the check
is returned by the bank due to insufcient funds, the next step in the licensure or certication process will be delayed until the fee is paid).
The optometrist license is $250.00 if you are applying the rst year of a biennial renewal period (between May 1st of every odd year
through April 30th of every even year). If you are applying for an optometrist license during the second year of a biennial renewal
period (between May 1st of every even year through February 1st of every odd year), your optometrist license fee will be $125.00. The
optometrist license fee must be submitted in the form of a check or money order made out to the State of New Jersey.
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Place of birth: ________________________
Dr.
City State Country
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: ______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: ____________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Attach a clear, full-face pass-
port-style photograph (2˝x 2˝) of
your head and shoulders, taken
within the past six months.
A photo is required with each
application.
Do not use staples to attach
the photo.
Reapply
License #
_________________________
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so may result in denial/nonrenewal of
licensure or certication.
*Social Security Number: __________ -________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Child Support (You must answer a, b, c and d.)
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d may result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
click to sign
signature
click to edit
6. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous substances. Please read the denitions carefully. Your responses
will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer this question if
you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you
may assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in
good faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on
the application. Your application for licensure or certication will be processed if you claim the Fifth Amendment privilege against
self-incrimination. You should be aware, however, that you may later be directed by the Attorney General to answer a question
that you have refused to answer on the basis on the Fifth Amendment, provided that the Attorney General rst grants you immunity
afforded by statutory law, (N.J.S.A. 45:1-20).
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
365 days, whichever is longer.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
a. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_________________________________________________ ___________________________________
Applicant’s signature Date
7. Haveyoueverchangedyourname? Yes No
If“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecerticate,divorcedecreeorcourtorder.
8. Haveyou everbeen summoned;arrested; takeninto custody;indicted; tried;chargedwith; admittedinto pre-trialintervention
(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle
violationssuchasdrivingwhileimpairedorintoxicatedmustbe.) Yes No
9. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,apleaofguilty,
nonvult,nolocontendere,nocontest,orandingofguiltbyajudgeorjury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole orprobation. Please provide a complete
explanation.(Attachadditionalsheetsofpapertothisapplication.)
10. HaveyouservedintheArmedForcesoftheUnitedStates? Yes No
If“Yes,”whattypeofmilitarydischargedidyoureceive?Indicatethetypeofdischargeyoureceived.
________________________________________________________________________________________________________
11. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionaloroccupationallicenseorcerticateofanykindinNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction? 
Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license was issued under a
differentname,pleaseprovidethatname.
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
12. Haveyouevertakenanyotherstateboardorregionalboard’sexamandfailed?  Yes No
If“Yes,”pleaseprovidethenameofthestateandthedatetheexamwastaken.
_____________________________________________________ ___________________________________
State Date
13. HaveyoueverbeencitedfordisciplinaryreasonsordeniedaprofessionaloroccupationallicenseorcerticateofanykindinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
14. Have you ever had a professional or occupational license or certicate of any type suspended, revoked or surrendered in
NewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
15. Hasanyaction(includingtheassessmentofnesorotherpenalties)everbeentakenagainstyourprofessionaloroccupational
practicebyanyagencyorcerticationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
16. Have you ever been named as a defendant in any litigation related to the practice of optometry or other professional or
occupationalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
17. Areyouawareofanyinvestigationpendingagainstaprofessionaloroccupationallicenseorcerticateissuedtoyoubyaprofessional
oroccupationalboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
18. ArethereanycriminalchargesnowpendingagainstyouinNewJersey,anyotherstate,theDistrictofColumbiaorinanyother
jurisdiction? Yes No
19. Haveyoueverbeen sanctionedbyor isanyaction pending beforeanyemployer,association, society, orotherprofessional or
occupationalgrouprelatedtothepracticeofoptometryorotherprofessionaloroccupationalpracticeinNewJersey,anyotherstate,
theDistrictofColumbiaorinanyotherjurisdiction? Yes No
If the answer to any of the above questions, numbers 14 through 19, is “Yes,” provide a complete explanation of the
circumstancesleadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
__________________________________________________________________
Last name First name Middle initial
Education
1. Whatisthenameandaddressofthehighschoolyouattended?_____________________________________________________
Nameofhighschool
_______________________________________________________________________________________________________
StreetaddressCityStateZIPcode
2. Whatyearsdidyouattendhighschool? _____________________
3. Didyougraduatefromhighschool? Yes No
If“Yes,”whatwasthedateofyourgraduation?___________________
MonthYear

If“No,”didyoustudytoreceiveaG.E.D.certicate? Yes No
If“Yes,”pleaseprovidethenameandaddressoftheeducationalinstitutionthatissuedyourG.E.D.certicateandthedate
the
certicatewasissued.
_______________________________________________________________________________________________________
Nameofeducationalinstitution
_______________________________________________________________________________________________________
StreetaddressCityStateZIPcode
______________________________________________
Datecerticatewasissued
4. Ihavestudiedoptometryfor____________ years_________monthsin_____________________________________________
Nameofoptometrycollege
and havebeen willbegrantedthedegreeofDoctorofOptometrybysaidcollegeonthe______________ dayof
________________________ ,20_____ .
5. Listpositions,internresidenciesorpostgraduatetrainingsincegraduationfromoptometryschoolincludingaddressesanddates.
(Accountforallyearssincegraduation.)
 Position  Internresidency  Postgraduatetraining
_______________________________________________________________________________________________________
Nameofeducationalinstitution
_______________________________________________________________________________________________________
StreetaddressCityStateZIPcode
From____________________________to____________________________
 Position  Internresidency  Postgraduatetraining
_______________________________________________________________________________________________________
Nameofeducationalinstitution
_______________________________________________________________________________________________________
StreetaddressCityStateZIPcode
From____________________________to____________________________
6. OETracker#_____________________
NationalBoardExamination NercoatsExamination
Scores
Part1 ______________
Part2 ______________
Part3 ______________
TMOD ______________
ContactNBEOtohavetheNercoatsresultssent.
Note: Nercoatsmayhavetoberesearchedbefore
results are sent to the Board which may
resultinashortdelayingettingresulsts.
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
Stateof:_____________________________________________
Countyof:___________________________________________
I, ___________________________________________ , in making this application to the New Jersey State Board of
OptometristsforlicensureorcerticationundertheprovisionsofTitle45oftheGeneralStatutesofNewJerseyandtheRules
oftheNewJerseyStateBoardofOptometrists,swear(orafrm)thatIamtheapplicantandthatallinformationprovidedin
connectionwiththisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuracies
orfailuretomakefulldisclosuresmaybedeemedsufcienttodenylicensureorcerticationortowithholdrenewalofor
suspendorrevokealicenseorcerticateissuedbytheBoard.
Ifurtherswear(orafrm)thatIhavereadN.J.S.A.45:12-1etseq.,togetherwiththeRulesandRegulationsoftheNewJersey
StateBoardofOptometrists,N.J.A.C.13:38-1.1etseq.,andfullyunderstandthatinreceivinglicensureorcerticationfrom
theBoard,Ibindmyselftobegovernedbythem.
Furthermore, Ivoluntarilyconsentto a thorough investigation of my presentandpastemployment and other activities
forthepurposeofverifyingmyqualicationsforlicensureorcertication.Ifurtherauthorizeallinstitutions,employers,
agenciesandallgovernmentalagenciesandinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,les
orrecordsrequestedbytheBoard.
_____________________________________________
Signatureofapplicant
Swornandsubscribedtobeforemethis_____________
dayof _________________________ ,____________
MonthYear
_____________________________________________
NameofNotaryPublic(pleaseprint)
_____________________________________________
SignatureofNotaryPublic
} ss.
Afx seal here
click to sign
signature
click to edit
click to sign
signature
click to edit
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Optometrists
P.O. Box 45012
Newark, New Jersey 07101
(973) 504-6440
CertifiCation and authorization form
f
or a Criminal history BaCkground CheCk
Directions:Answerallofthequestionsonthisform.
1. Name _________________________________________________________ ( ________________________)
LastFirstMiddle MaidenName
2. Address___________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode
3. Dateofbirth____/____/____ Sex: Male Female
MonthDayYear 
4. SocialSecuritynumber_________/_____ / ________

5. Haveyoucompletedthengerprinting processforanyBoard or Committee of the New Jersey Division of Consumer
AffairssinceNovember2003?
Yes No
If“No,”youwillreceiveaseparatemailingfromtheBoardorCommitteeregardingthecriminalhistoryrecordbackground
checkprocess.Nopaymentisnecessaryasofnow.
If“Yes,”pleaseprovidethefollowinginformationandfollowtheinstructionsoutlinedbelow:
_______________________________________________ _______________________________________________
BoardorcommitteerequiringthengerprintingMonthandyearyouwerengerprinted
IfyouwerengerprintedafterNovember2003aspartofthecriminalhistoryrecordbackgroundcheckprocessforlicensureor
certicationbyany otherBoard or Committee of the New Jersey Division of Consumer Affairs (abackgroundcheck
conductedfortheDepartmentofEducation,anotherstateagencyoranotherstatedoesnotapply),youwillnotberequiredto
bengerprintedasecondtime.However,theDivisionmustperformacriminalhistoryrecordbackgroundcheckeachtime
youapplyforlicensureorcertication.The fee for this service is $18.75.Paymentshouldbemadeintheformofacheckor
moneyorderpayabletotheStateofNewJerseyandshouldaccompanyyourapplicationpacket.
6. Haveyoueverbeenarrestedand/orconvictedofacrimeoroffense?(Minortrafcoffensessuchasaparkingorspeeding
violationsneednotbelisted.)
Yes No
Every such conviction on record must be disclosed. Atruecopyofeverypolicereport,judgmentofconviction,sentencing
orderandterminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployer
orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmitted
withthisform.Failure to follow these instructions may result in the denial of an initial application.
Note: Copiesofjudgments,sentencingandterminationofprobationordersmaybeobtainedfromtheclerkofthecounty
wherethoseorders,disposingoftheconviction,wereissuedandled.
Your continuing responsibility to disclose convictions of crimes or offenses:Youmust notifytheBoardorCommittee
withinve(5)businessdaysifyouareconvictedofanycrimesoroffensesafterthisformhasbeencompleted.
Mr.
Mrs.
Ms.
Ofcial Use Only
Dual License
License Type 1
_______________________
Applicant’s number
_______________________
License Type 2
_______________________
Applicant’s number
_______________________
Ofcial Use Only
Resubmit
Board or Committee
__________________
Rev. 1/19
CertifiCation
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
applicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefull
disclosuresmaybedeemedsufcienttodenycerticationorlicensureortowithholdrenewaloforsuspendorrevokeacerticate
orlicenseissuedbytheBoardorCommittee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requestedbytheBoardorCommittee.
Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymeare
willfullyfalse,Iamsubjecttopunishment.
_______________________________________________ ___________________________
Signatureofapplicant Date
New Jersey Ofce 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
Active Status Form
Please complete either the Active Status or the Inactive-Paid Status form.
An applicant applying for a license on active status must have a business address within the State of New Jersey in which he or she will
be practicing. Please provide your name of record, business name, business address and business telephone number.
Please print clearly.
Name of record _______________________________________________________________________________________________
Last name First name Middle initial
Business name ________________________________________________________________________________________________
Business address ______________________________________________________________________________________________
Street address City State ZIP code
Business telephone number ___________________________________ (include area code)
Licensee working at this location: ______________________________________________________
Licensee license number: 27OA00 _____________________ 00
Check one:
Pay $250 for the active-status license if applying for licensure during the rst year of the biennial renewal period. (Applying
between May 1st of every odd year through April 30th of every even year.)
Pay $125 for the active-status license if applying for licensure during the second year of the biennial renewal period.
(Applying between May 1st of every even year through January 31st of every odd year.)
___________________________________ __________________________________________
Date Applicant’s signature
Please Note
If you are submitting your application to the Board between February 1st odd year through April 30th of odd year, please call the Board
ofce at 973-504-6440 for the appropriate licensure fee or submit your application without the licensure fee and you will be notied in
writing of the appropriate licensure fee.
When applying for an optometry license on active status and an Oral T.P.A. Certication at the same time, you are only required to pay
one nonrefundable application ling fee of $125.00.
New Jersey Ofce 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
Inactive-Paid Status Form
Please complete either the Active Status or the Inactive-Paid Status form.
If you are not going to be practicing in the State of New Jersey or you do not currently have a promise of employment in the State of
New Jersey, you must apply for a license on inactive-paid status. Please provide your name of record and your mailing address below.
Please print clearly.
Name of record _______________________________________________________________________________________________
Last name First name Middle initial
Mailing address _______________________________________________________________________________________________
Street address City State ZIP code
Check one:
Pay $100 for the inactive-paid status license if applying for licensure during the rst year of the biennial renewal period.
(Applying between May 1st of every odd year through April 30th of every even year.)
Pay $50 for the inactive-paid status license if applying for licensure during the second year of the biennial renewal period.
(Applying between May 1st of every even year through -DQXDU\VW of every odd year.)
___________________________________ __________________________________________
Date Applicant’s signature
Please Note
If you are submitting your application to the Board between February 1st odd year through April 30th of odd year, please call the Board
ofce at 973-504-6440 for the appropriate licensure fee or submit your application without the licensure fee and you will be notied in
writing of the appropriate licensure fee.
When applying for an optometry license on inactive-paid status, your Oral T.P.A. Certication will not be issued until you have a
promise of employment and request to transfer your inactive-paid license to an active status.
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Optometrist Application Instructions Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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