ࡱ> \^[ $bjbj 08eeW& & 84%222   $%%%%%%$]'*l$%  $%229%!!!F22$!$!!#:$2p@ʆp$$O%0%$,{*SP{*:${*:$ !|   $%$%    %{*         & F:   State of fb88  MAINE BOARD OF OPTOMETRY APPLICATION TO PRACTICE OPTOMETRY IN THE STATE OF MAINEOPT Ck. # ___________Amt. ___________ Ungrad. Trans.___ O.D. Trans.___ NBEO I__II__III__TMOD___ CN __________________ CN _______________________ NAME____________________________________________________________________________________________________ Last First Middle Maiden ADDRESS_________________________________________TELEPHONE________________day_______________evening EMAIL ___________________________________________ BIRTHPLACE_______________________ BIRTHDATE____/____/____ SOCIAL SECURITY NUMBER ____-____-_____ City State Mo Day Yr EDUCATION Graduation from____________________________________ High School of ______________________________ IN __________ City State Year List in chronological order any college, university, or institution (other than optometry) that you have attended: MONTHS AND YEARS NAME OF INSTITUTION DEGREE (if any) _______, _____ to _______, _____ ________________________________________________ __________________________ _______, _____ to _______, _____ ________________________________________________ __________________________ _______, _____ to _______, _____ ________________________________________________ __________________________ List in chronological order any college or university of optometry that you have attended: MONTHS AND YEARS NAME OF INSTITUTION DEGREE (if any) _______, _____ to _______, _____ ________________________________________________ __________________________ _______, _____ to _______, _____ ________________________________________________ __________________________ _______, _____ to _______, _____ ________________________________________________ __________________________ Received Degree of optometry in _________________ of _____ from _____________________________ Expect to receive the Degree of optometry on the _____ day of _________, _______ OE Tracker # _____________ Did you successfully pass the NBEO Part I? Yes___ No___ year passed _______ awaiting results _______ Did you successfully pass the NBEO Part II? Yes___ No___ year passed _______ awaiting results _______ Did you successfully pass the NBEO Part III? Yes___ No___ year passed _______ awaiting results _______ Did you successfully pass the TMOD Section? Yes___ No___ year passed _______ awaiting results _______ List all states, Territories, and Countries in which you have possessed a license to practice optometry (If none, so state) Jurisdiction Date of issue Active/Inactive Years of practice __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Using a separate 8 1/2 X 11 sheet of white paper signed, notarized, and dated, and enclosed with your application; respond to the following three items: List in chronological order all professional experiences since optometry school, including all periods from the date of graduation until the present, whether or not engaged in activities related to optometry. Include military assignments. 2. Are you currently in active practice? Yes___ No___ If you have not actively practiced for the past six months, explain. 3. List optometric continuing education courses taken during the past two years. PERSONAL DATA Check the appropriate response. Any yes response must be fully explained by written statement on a separate 8 1/2 x 11 sheet of white paper, signed, notarized, and dated, and enclosed with your application. HAVE YOU EVER: 1. Been denied optometric licensure in any state? 1. No __ Yes __ 2. Possessed a license to practice optometry that was suspended, revoked, or subject to other disciplinary action? 2. No __ Yes __ 3. Had your practice privileges restricted? 3. No __ Yes __ 4. Had a physical or mental illness which necessitated the suspension of your optometric education or practice for more than 30 days? 4. No __ Yes __ 5. Been arrested with or without conviction(s) for any offense including driving while intoxicated (i.e. OUI, DWI, DUI) but not including other minor traffic violations? 5. No __ Yes __ 6. Been formally noticed by a court of a pending (as of the date of this application) claim or suit alleging malpractice liability or settled by negotiation/arbitration, or court judgment any claim of malpractice liability in which you are/were named as a defendant by your insurance company/representatives without your express consent? 6. No __ Yes __ (Dismissals need not be reported.) AFFIDAVIT OF APPLICATION I, ___________________________, first being duly sworn, depose and say that I am the person described and identified in this application. I have carefully read the questions in this application and have answered them completely, without reservations of any kind, and I declare that my answers and all statements made by me herein are true and correct. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for denial of my license to practice optometry in the State of fb88. I hereby authorize all institutions or organizations, my references, employers (past and present), business and professional associates (past and present), and all governmental agencies to release to this licensing Board any information, files, or records required by this Board for its evaluation of my professional and ethical qualifications for licensure in the State of fb88. I hereby authorize the Board of Optometry to transmit any information contained in this application, or information that may otherwise become available to them, to any agency, organization, or individual, who, in the judgment of the Board, has a legitimate interest in such information. APPLICANT MUST SIGN FULL NAME IN THE PRESENCE OF A NOTARY PUBLIC, RECENT PASSPORT WHO MUST COMPLETE THE AFFIDAVIT AND AFFIX NOTARIAL SEAL OVER A PHOTOGRAPH IN PORTION OF THE PHOTOGRAPH. THIS SPACE Subscribed and sworn to before me this ________ day of ___________________, 20___. Notary seal must Notary Signature _________________________________________ cover portion of photograph Notary Public for the State of _______________________________ My commission expires ___________________________________ _______ _____________________ (Signature of Applicant)      FILENAME \p G:\HEALTH\Optometry\Application and Exam\Application.doc  lopq    } 8 : J L ,./1AC#%y¼¶°°¼¼ h]]YCJ hLe*CJ h5CJ h)CJ hap?CJ hCJ hCJ hd.5CJ hZ5CJ hzR5CJ h5CJ hap?5CJ h5hY:jhzx0Uh> 4lpq $IfgdzR$If $$If]a$ $$Ifa$$F$-DIfM ^Fa$gdY:$F$-DIfM ^Fa$  y    > ' u / $a$Zkd`.$$IflFnH!, 2@     4 la/ &yz)*EFu\23gdQKyz!#)*6DEF236?@D7!!!!!!##%#P$^$h$i$r$~$ hCJ hap?CJ hd.CJ hLe*CJ h5CJ hs5CJ hzRCJ hQKCJ hXCJ h CJhh h h CJ h CJ hl=CJ h]]YCJ hCJ hCJ6CDWAgdap?$a$gd  & Fgd f{67PQ !!!R"""",#I#####P$$a$P$$$$$$$$$$$$$$gdap? ~$$$$$$$$$$$$$$$$$$$h20hwmHnHuhGejhGeUh]$jh]$Uhap?hCJ.:p / =!"#Z$.% `.Dd <  C A2-.Y1E a-D`!-.Y1E ab؊>r-xOh#Yzry\nָz!jzM$2w{!Y29${Ɠ7hUe4& sH/1C 3hڃ ̶KкK}Jܭ̔%Uկޟ}d //X^_[Xj366*_U|}SXo?{Q- `VV߇ꭨ+X5R}6i:29B -ms ݕ-Uo:.?`{ Q^rUU*W\rUJhj0K#/QbpY=-ϸ'1^˖g#oἤ4WSfhhOGNDFnqQ3#(6K83C~Dܠd p&Yl}n]YK4HҳR#ByQR3|n2#ZBԫ nf p^3K|:*%tweza7zRxZ ԁ02VXfYɡNgN3}|+EQv3s^7 d{+~PN2VQBN[=41dέN+K01zdWܰ<2L | 2zEB&AX7Wy7f|6H^U~,?u ܍b:8s)s17p_(' ~:JdAΤjp2a &uH6Wa0#/R A^^1#䨟ZN 9RGUE)p& 5 6NŨ,D[ 5Q3;yY„և1Cza<j wck[q*\?cO!|gptrKul9'9T>|J5 c`+cmeg;ד X'R}G h@qybP ~Xo0/`(.d|Ҏ`%/d\vD^vLHZR{/^:!TIf`Qt _^~f!Y%2ul F2c}iˢP${ \bmԩ2OҦYyIgjXP|2PuuRO݋g6&:3%d5efX֟aI:]0Ap fnE9QS̨3GH)6F1YXfu0Jc\KN$[Ȱ r@ElNgf|sqPTIf2lE}FxP*tCQ7Qf`s.V3C =ʞN'\;UU NdSe>bR/!s^D(. 9 ,aqYsbFD@Έ|"ÓԎOoILH7³A*<.~FhKxbC2~xrJJ ;*4N֤T2IKJ[*fӘ{A/; Êؒ 21Ml;1,d4= G6a\FAʆk(64g.Sp}>¥W18$=H<&R-Ho0~^bY%\V/$15AoDTTpٽ_5 ,bLB `#mȰyxxOdl~Ku U2*c$|FPZjBBh؆3M}Аr ]@xi G/c#Lj9Űd3q d PLGHb8Ԏ TS:pDGZ*$՝^ B9b~"R'372D}=Ow041>qq;yf'aLChj`"rb;!2kyL66"̀xV㵸/|.CEGhlŚ0fn6X3wL@Pk\RVH`3.?J|57y0:L3a_{b wpj4U2w:.ʑAYn;GSr[Bb!󙝛e81#36eoa0=CI}iߏOȀOxPm c= |3ܕF `'祴a Lv>vD!s[R'8P8ܹk O1 1WU*@>|Xbl'yn~F?)aɜBzĈ`b0Z4ʋ #'7}b b*r "7A燸R'K:~Q;@|wG7TG9 ꎭ<*-vhwH_u+)=#=3G>`4{ ?i\; M1cKU#>30lGԛ#*bl;Ν$[ ~WX_> J$^uBf@zccʰPq7䓖2x5a3f l=4XЕ+D[\9)A s}~iΘw"'c#:ܤV<+ފhr14t3ֳ1y63:z^R WW9ArLI1좥tYUËCpP9A!RbhQ O 5 "Z]H~cƑ%*`xa~۱sc A_;~QѽJo31 ev14?)B薚= >0dh^ajQ#aUq݈T;Jmc0Ÿ3س#vBvPcBc(jWB~[,Fߐ3!kq3`ڜ]A7ɪ%8F7U.4;;oL)%U215d0U2+f%Q_oy)-)W% 'ؔ'EhF߈Wz0cO <1 * 70ȃHMWȠd2hU#5Rv<ߍcn";C;V6-WX3tx $$lk%dCQ"S`}߆#߰%Îӟ"Z L#`Tԇk'ϔ͏Ǖ QSFl:Yħlx鱽Ȯ|i10|0) x_E.Y4MAtE)x1 X5;5Uޫ|ݜA6]U{U^ H1`B H؊/c}DJ.,+(} Y>wodd !-bW3/!~ kVDٌ{kvA.: >_bP39- dpw;Q?0uӥ` gß`^8( ]!1zFz4_bMr3B6U1lUCt0`7`ca,!nl`]#.km屄qF9`xVuɴ6h} ȵ Ai8a5/ ޿Q`OLp-2[xDc[lӼnGvx2,olypia!*>evaf˃/9mq } _qv4?`WAYC-iIʊØ}3`6 -;7y:h[1o+[`.`0/^ܪRKl=*0c<3gR[ N6j%(A0*1:f]5]a;7V寮G՛z.nc[HAme`\ۓ`܌6 \_pZf\rgo)wΰ~ 62zm,.~ws?h}+S0EaQϼ2MF{J]a[,0։q8@z7X5t: +wGWE m``:؟rX*Tu+х[?6. FSfm@Ɲ.bXkOA0Z[yT` pd`J% ƻoV`۱(gjkTUd4!0}bpJYY ZJڏXQeS^Y~kQ]cVG0Ԧ*0SіUd QMQݨH*'tTbAnDzzb\qa}rV6+טnh}rkyaD:f|[1[pu91։>Ef ApyQq^$%b,L<0:Bp{Y`0r2N]b2rmǍ`a0("-kKn2=ۯQ(ԳU1Վڒ=ns+ICC_;?M:$R+e0Z9' W`XtFqޫwknD}FqOmA\qg;J+|W`ܴWKx i)No=bZoY2 w`⚬Lgg9I&W+`MgO95Sqoh<6鰏ȼca0ѾS=օwxRPSq#Z G݃)}N,[I/ek' $]3`X-վ$8n&xȁ~HZ'5 Y*b;rs `Up0H{h5ȎP/{dCk7gr}¤5mXVR* !lO쌆sٰсOK. cY^K bb}O#1aFx,jp¾?9M2AoiG"M/\.p>z? L.=ۗy218;Tl`XnxTkb$?l:qJhwIU#*VwP7 Z&ͽ/"7h?PU̇i@Ξ8z\>摚ȱק/2tMW#n>!><4y>u0#:Lmnf08 =^fG[7{;<V$zzj'q+ |~?p ҷ 'vWٿ7Y1҉֒b:8$=!\~ -O ,''=n9JL7lc9?;ts]n%C|a*@atꚲ@ǝ?F <9y=z7mEg+fuc^{@ Wm<B"C ލj G@:%dY 'v@]pBk7f` }0~Yttx*+z;!ÌtFߖ>&Y( Nx@*F#OÿC9+*G<1햨mOG5O9f wF۠hcֱ%͊:C:z/8Dcouu_T:YNIw-eGqʀ@0!ܣ#Lc CW}1PǪbf0Rױ&o"S˺M!?5 ,btGRR0Ƹkh~Obs3 {k}rvgΠw=môpCShZj9[)|1\`Ô"2hː(R4ͱp-\L\' mV()zw*mH_QJu׌ຜ`1g MhZclzH-P2I =a}Ey S +X`G/ndK ?$qҗ uzW>t*e!&ӟO( S:+y 8D.L&錘]|hHM(ph136*^2 úM !n2)(} Es2̬ 㦍 i^7 #r{7 GśX6Z+|xJ2kQ렘ד [_TBю'x?yMJr3g,(K ]!}j3.1X#JLm `ab^ҵkh1 ZV'``uG `F`t:HrN+JFHqw'1 -7)W+#pntXW'xím kndX`,-NZ|tZsFɓAx4YL:Y칎qR+ӟ!CcŤ 'l#0t]:Zpp;W Q@mqy)196gL |0^Ӄ c nG?HY?!c5/jKjnhnn'|b8TJWd~DZ)2lu8+\"0Q*tbHIgwal60MXvC:>ɩn!7<IqMqּ'(49ur'ƕ5wj85LMfۑAL0>$'4h0sHUO0 gA{; #Ij{y/,N" ;]{]OV={zWz!0: l{T/JNsC0kOaTP89fbޜVN*¿P\S/WpyWɵbN_ JeċeɈ8tJОBtyF8Т`Uev|'~^T# #:5yl Sj ?<~άkk-{}$嫿J`!ʌybޒX'ayXayXayXYZ&5w]Ϟ1)9d$$If!vh#v #v2#v@ :V l5 525@ 4a^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8 Normal_HmH sH tH L@L  Heading 1dCJOJQJkHP@"P  Heading 2dxx5CJOJQJkHD@2D  Heading 3dxx5CJDA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List J>@J Title$da$CJ0OJQJkHDOD Body SingledCJO Bullet 1n & Fd>ThxCJO" Bullet 2n & Fd>ThvCJ`O2` First Line Indent d^`CJOB Number Listn & Fd>Th.CJOR Outline Numberingn & Fd>Th.CJJObJ Table Text dCJFOrF Default TextdCJH@H M$~ Balloon TextCJOJQJ^JaJ44 GeHeader  !4 @4 GeFooter  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] 8 VVVYy~$$ / P$$ SY8@0(  B S  ?               ffooII      kktNN   9*urn:schemas-microsoft-com:office:smarttagsplace9*urn:schemas-microsoft-com:office:smarttagsState8 *urn:schemas-microsoft-com:office:smarttagsCity=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName  lo }~~lo   }//8:JL,./1AC#%! # ( ) * E 6?#%++,,//rr~~lo   }( ) * E 6?rr~~y'~Z$^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.y'         &%!E@Gep$Le*d.20zx0v5Y:;ap?uxHO#'Q]]Y \ i;l1sEtw.wM$~ ]$QKszRXZ4)l=Z@~~~~@UnknownG* Times New Roman5Symbol3. * Arial?. Arial Black3* Times;. * Helvetica5. *aTahomaA$BCambria Math"+'+'+'@?3@?3Y4qq3QXZ ?M$~2!xx Board of Optometrytina.carpentier Oh+'0 $ D P \ ht|Board of Optometry Normal.dotmtina.carpentier2Microsoft Office Word@F#@l4@Æ@Æ@?՜.+,0 hp|  PFR3q  Title  !"#$%&'()*+,-./012346789:;<=>?@ABCDEFGHIJLMNOPQRTUVWXYZ]Root Entry Fp@ʆ_Data .1Table5*WordDocument08SummaryInformation(KDocumentSummaryInformation8SCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q