"Application for Temporary License
Pursuant to Section 3046.1 of the Business and Professions Code, the board shall issue a temporary license to practice optometry to any person who applies for and is eligible for licensure pursuant to Section 3046 of the Business and Professions Code, but who is unable to immediately take the Section III - Clinical Skills Examination developed by the National Board of Examiners in Optometry (NBEO), required for licensure under this chapter, due to the state of emergency, proclaimed by the Governor on March 4, 2020, in response to the COVID-19 pandemic. If eligible, you must also meet and maintain the following requirements to be a temporary licensee:
To apply to be a temporary licensee, provide documentation for item (2) above with your application. All documentation must be provided, or the application will be rejected.
First, Middle, and Last Name: |
Address (City, State, Zip Code): |
Phone Number: |
Email Address: |
Social Security or ITIN number: |
Date of Birth: |
Name of School of Optometry: |
Address of School of Optometry (City, State, Zip Code, Country): |
Date Degree Conferred: |
Name and License Number of Supervising Optometrist: |
Date you completed the CLRE: |
Regulations require the submission of fingerprints prior to issuance of the temporary license. Due to a change in the regulations, fingerprints are now checked by the Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). Live Scan is required for California residents and a Manual Fingerprint Card is required for non-California residents. |
I declare under penalty of perjury under the laws of the State of California that the information provided on this form and the attached documents or other requested proof of completion is true and accurate. I understand and agree that any misstatements of material facts may be cause for denial of the Application for Temporary License and disciplinary action by the State Board of Optometry. |
Applicant Signature: |
Date: " |
"Application to be a Supervising Optometrist
Pursuant to Section 3046.1 of the Business and Professions Code, an individual may act as supervising optometrist to a temporary licensee, as defined in that section, if they meet the following conditions:
To apply to be a supervising optometrist, provide documentation for items (1) and (2) above with your application. All documentation must be provided, or the application will be rejected.
First, Middle, and Last Name: |
Address of Record: |
Phone Number: |
Email Address: |
License Number: |
Name of temporary licensee whom you will be supervising: |
1. I declare under penalty of perjury under the laws of the State of California that the information provided on this form and the attached documents or other requested proof of completion is true and accurate. I understand and agree that any misstatements of material facts may be cause for denial of the application to be a Supervising Optometrist and disciplinary action by the State Board of Optometry. |
AND |
2. I declare under penalty of perjury under the laws of the State of California that I will comply with all duties as a supervising optometrist set forth in Section 3046.1 of the Business and Professions Code, and that pursuant to that section, I am legally and professionally responsible for the actions of the temporary licensee which may result in action being taken against my license in cases of temporary licensee misconduct. |
Applicant Signature: |
Date: " |
Ca. Bus. and Prof. Code § 3046.1