Trade Name Application
Additional Applicants
Attach additional applicant(s) information, if necessary
PRACTICE LOCATION(S). Please list all anticipated practice locations where application is being made for approval to use the trade or assumed name:
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TRADE OR ASSUMED NAME REQUESTED: Please list the trade or assumed name you are requesting and any alternates in order of preference:
Articles of Incorporation
Copy of the draft or filed articles of incorporation or articles of organization
*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.
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CERTIFICATION OF APPLICANT(S). By typing their name below, each applicant certifies to the Kansas Board of Examiners in Optometry that each, individually:
Please check all that apply
OR
AND
SIGNATURE OF APPLICANT(S). Each applicant listed above must provide an electronic signature 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.
Perjury statement. I hereby swear or affirm under penalty of perjury that the information given herein is true and correct to the best of my knowledge or belief.
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Signature(s) of additional applicant(s)