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Get Applying To Be An Optician Form

) and/or jurisdiction(s) where you are or have been licensed, certified, or registered. Instruct them to return the form directly to the above address. Make a copy of this form if you need to send it to more than one state or jurisdiction. Agencies normally charge a fee for verification. Please check in advance to help expedite this process. Name: Last First Middle Mailing Address City State Zip Code Any other names used: License, Certification, or Registration Number D.

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