PRACTICE LOCATION(S). Please list all anticipated practice locations where application is being made for approval to use the trade or assumed name:
TRADE OR ASSUMED NAME REQUESTED: Please list the trade or assumed name you are requesting and any alternates in order of preference:
*The applicant must also request and obtain a certificate from the Board certifying the individuals to engage in the professional services are duly licensed by the Board.
CERTIFICATION OF APPLICANT(S). By typing their name below, each applicant certifies to the Kansas Board of Examiners in Optometry that each, individually:
SIGNATURE OF APPLICANT(S). Each applicant listed above must provide an electronic sigure by typing their name below. Applications are approved at board meetings held in January, April, June, and October. There are no exceptions to this schedule.
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