Trade Name Application

Name - Applicant A

Address - Applicant A

City - Applicant A

State - Applicant A

Zip Code - Applicant A

Phone Number - Applicant A

Email - Applicant A

License Number - Applicant A

Name - Applicant B

Address - Applicant B

City - Applicant B

License Number - Applicant B

State - Applicant B

Zip Code - Applicant B

Phone Number - Applicant B

Email - Applicant B

PRACTICE LOCATION(S). Please list all anticipated practice locations where application is being made for approval to use the trade or assumed name:

Location(s)

TRADE OR ASSUMED NAME REQUESTED: Please list the trade or assumed name you are requesting and any alternates in order of preference:

1st Choice

2nd Choice

3rd Choice

Will you be registering name with Kansas Secretary of State?

Yes
No

Name* that will be submitted to Kansas Secretary of State:

*65-1522. Professional corporations, Limited Liability Company, associations, sole practitioners; practice locations, franchise agreements. (a) A licensee may practice optometry under the name of a professional corporation, authorized by K.S.A. 17-2706 and amendments thereto or a limited liability company authorized by K.S.A. 2002 Supp. 17-7668 and amendments thereto. Such professional corporate name or limited liability company name may contain a trade name or assumed name approved 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:

Please check all that apply

Has made a reasonable search, including contact with Kansas Secretary of State, review of local telephone books and the approved trade name list (posted on the Board's website), and internet for the present and anticipated practice locations and is unaware of any persons or entity using the trade name or assumed name applied for or a name so similar to the one(s) applied for as to create a potential confusion;

Yes

Has obtained permission to practice under an existing trade name as listed above;

Yes

AND

He or she intends to actively engage in the practice of optometry under the trade name or assumed name applied for, if approved, within 6 months of approval.

Yes

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.

Applicant A Signature

Applicant B Signature

Applicant A Date

Applicant B Date

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