APPLICATION FOR LICENSEES TO BE CERTIFIED TO USE PHARMACEUTICAL AGENTS

Name:

________________________________________________________________________

Addresses of all practice locations (use reverse of page if necessary):

________________________________________________________________________

Telephone(s):

________________________________________________________________________

Present license number:

________________________________________________________________________

Attach to this form the following:

1. 1. Your check for $110.00 ($100 therapeutic license + $10 to
   fund the Prescription Drug Monitoring  Program as required
   by Alabama Law).
2. 2. Proof of attending seventy­two (72) Board approved clock
   hours in the diagnosis and management of  diseases of the
   human eye and its adjacent structures taken within a three
   year period preceding this application.

3. 3. A completely filled out form entitled “PROTOCOL FOR THE
   THERAPEUTIC USE OF PHARMACEUTICAL AGENTS FOR THE TREATMENT
   OF DISEASES OF THE EYE AND ITS ADJACENT STRUCTURES.”

   ________________________________________________________________________
   Signature of applicant