Name Change Request - Nevada State Board of Optometry

I,*

, Nevada Optometry License No.*

Wish to change my name to, and to display on my optometry license certificate as:*

I would like my new optometry license certificate to be mailed to:*

I would like the new location card(s), Optometric Pharmaceutical Agent Certificate (OPAC), and Glaucoma certificate, if applicable to be emailed to:*

Please upload a copy of your legal name change document, court order granting petition for name change, or marriage license.*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 20 MB, Max. files: 10.

Application Fee

Price:

Total

$0.00

By submitting this information and checking this box, I affirm that each document is complete and correct and that all information contained in this submission is true under the pains and penalties of perjury and the requirements of NRS Chapter 636 and NAC Chapter 636 and Nevada law generally. I also acknowledge that if I have directed or authorized another to complete or submit this information on my behalf, I, the optometrist licensed by the Nevada Board of Optometry, am fully responsible for the content of this submission.

Name*

First

Date*

Billing Address*

Street Address City State ZIP Code

Comments

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