Arkansas State Board of Optometry

ARKANSAS STATE BOARD OF OPTOMETRY 2018 DUPLICATE BRANCH RENEWAL APPLICATION FOR CERTIFICATION AS AN OPTOMETRIC PHYSICIAN ——————————————————————————————————————— PAYABLE TO: ARKANSAS STATE BOARD OF OPTOMETRY Board Address:

Required Fee: $ 25.00 (If paid on-line, do not send) P O Box 512 Due: February 1, 2018 Searcy, AR 72145 ———————————————————————————————————————

NAME:______Primary office address:______City, State, Zip Code:______

MAKE CORRECTION ON MAILING ADDRESS IF NECESSARY ——————————————————————————————————————— FEDERAL DEA # ______LICENSE #:______PRIMARY OFFICE PHONE: ______BRANCH LIC #: ______DRUG CER: ______BRANCH OFFICE PHONE: ______OPT PHYSICIAN #: ______

BRANCH OFFICE ADDRESS:

STREET: ______CITY:______BRANCH ZIPCODE: ______BRANCH COUNTY: ______

IF THE ABOVE IS BLANK OR INCORRECT, PLEASE COMPLETE OR CORRECT. THE DEA REQUIRES A STREET ADDRESS FOR YOUR PRACTICE LOCATION. ———————————————————————————————————————

——————————————————————————————————————— For renewal, you need to provide the following information to the Board:

______1. A statement to the Board, that you have established a written procedure in the event of an emergency situation in your branch office.

______2. Include a fee of $25.00 _____CHECK HERE IF YOU NEED A LARGE CERTIFICATE FOR FRAMING TO BE DISPLAYED AT YOUR BRANCH OFFICE

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E-Mail Address: ______Date:______Signature:______