Ala. Admin. Code r. 630-X-A-8
Rule 630-X-13-.05
APPLICATION FOR THE ISSUANCE OF A CERTIFICATE OF QUALIFICATION FOR A SPECIAL PURPOSE LICENSE TO PRACTICE OPTOMETRY ACROSS STATE LINES
Full name of applicant__________________________________________
Residence Address ______________________________________________
City, State and Zip Code________________________________________
Residence Telephone Number______________________________________
License number and name of state in which you currently practice ____________________________
Applicant must do the following:
Have your State Board of Optometry send to the ALABAMA BOARD OF OPTOMETRY evidence that the applicant holds a current, full and unrestricted license to practice optometry and that there are no previous or pending disciplinary action or other action taken against the applicant by any state or other licensing jurisdiction.
Enclose the application fee of $600.00.
By signing this application the applicant affirms his or her intent and willingness to report to the ALABAMA BOARD OF OPTOMETRY in writing the initiation of any disciplinary action against him or her by any state or territory in which he or she is licensed. Said report shall be submitted to the ALABAMA BOARD OF OPTOMETRY within 15 days of the initiation of such disciplinary action.
Signature of Applicant__________________________________________
Date_________________________________________________________________________________
ALABAMA BOARD OF OPTOMETRY
1431 Second Avenue, North
Bessemer, AL 35020