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

Additional Applicants

Attach additional applicant(s) information, if necessary

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

Do you intend to practice or are you currently practicing under the name of a professional corporation or professional limited liability company authorized by either KSA 17-2706 or KSA 17-7668? If yes, provide the name of the entity, the owners of the entity (shareholders or members) and all licensees practicing under the name of the entity. Also, provide a copy of the draft or filed articles of incorporation or articles of organization.

Yes
No

Name of Entity

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.

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
No

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

Yes
No

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
No

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

Signature(s) of additional applicant(s)

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