[STAGING] Application Apprentice Form

1. Are you a veteran or service member? For purposes of this application, a veteran is defined as a person meeting one or more of the following qualifications (this information is collected per NRS 417.0194):*

Yes No

(a) Have you ever served on active duty in the Armed Forces of the United States and separated from such service under conditions other than dishonorable?

(b) Have you ever been assigned to duty for a minimum of 6 continuous years in the National Guard or a reserve component of the Armed Forces of the United States and separated from such service under conditions other than dishonorable?

(c) Have you ever served the Commissioned Corps of the United States Public Health Service or the Commissioned Corps of the National Oceanic and Atmospheric Administration of the United States in the capacity of a commissioned officer while on active duty in defense of the United States and separated from such service under conditions other than dishonorable?

2. Are you subject to a court order that requires you to pay for the support of one or more children? This information is collected per NRS 425.520*

Yes No

(a.) Are you in compliance with that order?*

Yes No

3. Do you have a Nevada business license? (This question pertains to a license to own/operate a business, not to your occupational license to practice; this information is collected per NRS 353C.1965):*

Yes No

Business Name:*

Business License Number:*

4. Have you ever had disciplinary action taken against your occupational or professional license or privilege to practice, or certification/registration of any kind (other than your driver's license or vehicle registration) or surrendered a professional license in any jurisdiction?*

Yes No

NOTE: You must give a written explanation of the action(s) against you and upload any supporting documentation

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5. Have you ever had a criminal conviction (other than a minor traffic violation), whether misdemeanor or felony, or a civil judgment rendered against you in any jurisdiction?*

Yes No

NOTE: You must give a written explanation of the action(s) against you and upload any supporting documentation

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Affirmation

I affirm under penalty of perjury that all representations I have made in this application are true and complete in every respect. I hereby authorize the Nevada Board of Dispensing Opticians to make any inquiries it deems necessary to verify the accuracy and completeness of all representations I have made as part of my application.

Signature *

Date

*Your signature affirms you have reviewed, understand, and will fully comply with the provisions of Chapter 637 of the Nevada Revised Statutes (NRS) and Nevada Administrative Code (NAC) that govern the practice of an apprentice optician (these laws and regulations are available on the Board’s website: www.nvbdo.nv.gov).

**Per Nevada Open Meeting Law provision: NRS 241.033(l)(a) and (b), if the board sees cause to review your application at a public meeting, you must receive notice of the time and place. The notice must be served to you in person at least five (5) working days prior to the meeting date, or via certified mail at least twenty-one (21) working days prior to the meeting date.By signing this application, you agree to waive your legal right to such notice, and to allow the board to review any and all portions of this application at its next regularly scheduled board meeting.

Nevada Board of Opticians

Application for Apprentice Ophthalmic Dispenser License

Mailing Address:

Previous License History :

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