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VISUAL ACUITY EXAMINATION FORM Instructions Applicants This form must be submitted for all welder original and renewal applications. Be sure to keep a copy of this form for your records. Your application for an original or renewal license will not be accepted unless a completed Visual Acuity Examination Form is submitted. The examination must occur and this form must be completed 1 year 12 months prior to the date of application for an original or renewal welder license. One of the following is required to administer the eye examination Ophthalmologist Optometrist Medical Doctor Registered Nurse or Certified Physician s Assistant. All applicants must pass an eye examination with or without corrective lenses to prove near vision acuity on Jaeger J2 at 12 inches or greater 30. 5 cm. Examination results must be documented on this form and submitted with your application* The Department of Buildings will not accept forms that are incomplete or test results that do not comply with fitness requirements. 1 Applicant/ Licensee Information Application Type Original Welder License First Name Renewal Welder License Last Name License THE FOLLOWING TWO SECTIONS ARE TO BE COMPLETED BY THE EYE EXAMINER 2 Vision Acuity Please verify the applicant s near vision acuity to Jaeger J2 specifications at a distance of Both eyes require corrected vision to J2 Only one eye needs corrected vision to J2 No correction is required* 3 Examiner Applicants Name Date of Eye Examination Telephone Number Examiner Name Examiner Address City State Zip Examiner Professional Status please select only one Ophthalmologist Medical Doctor Examiner Signature and Stamp If Stamp is Available Date Registered Nurse State/Prov* Certified Physician s Assistant LIC 60 12/11. One of the following is required to administer the eye examination Ophthalmologist Optometrist Medical Doctor Registered Nurse or Certified Physician s Assistant. All applicants must pass an eye examination with or without corrective lenses to prove near vision acuity on Jaeger J2 at 12 inches or greater 30. All applicants must pass an eye examination with or without corrective lenses to prove near vision acuity on Jaeger J2 at 12 inches or greater 30. 5 cm. Examination results must be documented on this form and submitted with your application* The Department of Buildings will not accept forms that are incomplete or test results that do not comply with fitness requirements. 5 cm. Examination results must be documented on this form and submitted with your application* The Department of Buildings will not accept forms that are incomplete or test results that do not comply with fitness requirements. 1 Applicant/ Licensee Information Application Type Original Welder License First Name Renewal Welder License Last Name License THE FOLLOWING TWO SECTIONS ARE TO BE COMPLETED BY THE EYE EXAMINER 2 Vision Acuity Please verify the applicant s near vision acuity to Jaeger J2 specifications at a distance of Both eyes require corrected vision to J2 Only one eye needs corrected vision to J2 No correction is required* 3 Examiner Applicants Name Date of Eye Examination Telephone Number Examiner Name Examiner Address City State Zip Examiner Professional Status please select only one Ophthalmologist Medical Doctor Examiner Signature and Stamp If Stamp is Available Date Registered Nurse State/Prov* Certified Physician s Assistant LIC 60 12/11..

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