Last Name:		First:			M.I.:
Contact Information
Street:
City:		State:	AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NB NF NT NS ON PE PQ SK YT AS GU PR VI	Zip:

Day Phone:		Evening Phone (if different):
Email:

Are you licensed to practice Optometry?  Yes  No

If so, in which states?

Are you licensed to use pharmaceutical agents for therapeutic purposes?  Yes  No

List the undergraduate schools you have attended in chronological order:
Name	Location	Dates of Attendance	Degree or Number of Units Earned
List the graduate and professional schools you have attended in chronological order:
Name	Location	Dates of Attendance	Degree or Number of Units Earned
Please attach your curriculum vitae, specifically including: A list of where your work experience, in chronological order. If you were in private practice during a period, state so. Include military experience if applicable. Include your current practice mode. Complete contact information for three specific individuals who can serve as references in regards to your professional record. Papers, publications, honors, and awards.
Have you ever been convicted of an offense other than traffic violations? Yes  No
If "Yes", please state facts:
By clicking the "Submit Application" button below, I attest that the statements that I have made in this application are true to the best of my knowledge and belief.