<p> 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:</p><p>Required Fee: $ 25.00 (If paid on-line, do not send) P O Box 512 Due: February 1, 2018 Searcy, AR 72145 ———————————————————————————————————————</p><p>NAME:______Primary office address:______City, State, Zip Code:______</p><p>MAKE CORRECTION ON MAILING ADDRESS IF NECESSARY ——————————————————————————————————————— FEDERAL DEA # ______LICENSE #:______PRIMARY OFFICE PHONE: ______BRANCH LIC #: ______DRUG CER: ______BRANCH OFFICE PHONE: ______OPT PHYSICIAN #: ______</p><p>BRANCH OFFICE ADDRESS:</p><p>STREET: ______CITY:______BRANCH ZIPCODE: ______BRANCH COUNTY: ______</p><p>IF THE ABOVE IS BLANK OR INCORRECT, PLEASE COMPLETE OR CORRECT. THE DEA REQUIRES A STREET ADDRESS FOR YOUR PRACTICE LOCATION. ———————————————————————————————————————</p><p>——————————————————————————————————————— For renewal, you need to provide the following information to the Board:</p><p>______1. A statement to the Board, that you have established a written procedure in the event of an emergency situation in your branch office.</p><p>______2. Include a fee of $25.00 _____CHECK HERE IF YOU NEED A LARGE CERTIFICATE FOR FRAMING TO BE DISPLAYED AT YOUR BRANCH OFFICE</p><p>———————————————————————————————————————</p><p>E-Mail Address: ______Date:______Signature:______</p>