Application for Lapsed License Renewal Form

Application for Lapsed License Renewal Form: Candidates for License as Dispensing Optician and/or Contact Lens Fitter in the province of Newfoundland and Labrador. Application Fee: $400.00 for Optician; $510.00 for Optician/Contact Lens Fitter [non-refundable]. Please make cheque payable to the Dispensing Opticians Board of Newfoundland and Labrador.

Please complete this form and enclose pertinent documentation for preliminary consideration.

Name

Address

Phone:

(H)

Email

(W)

Email

(Fax):

Is English your preferred language?....

Yes

No

What other language(s) do you speak?

Answer the following sections and provide requested documentation:

How long were you licensed in Newfoundland and Labrador?

What was your professional status?

Are you a Canadian citizen?

Yes

No

Please provide a current (within the past 3 months) affidavit for criminal record check / letter of conduct.
Max. file size: 64 MB.

Do you hold License status in another Province?

Yes

No

IF YES, List the provinces in which you have held license. Are these licenses current at this time?

Do you intend to reside and work in Newfoundland and Labrador?

Yes

No

If no, please explain

Please attach documentation confirming you have Professional Liability Insurance from the Newfoundland Guild of Dispensing Opticians /Opticians Association of Canada.
Max. file size: 64 MB.

Eyeglass Dispensing requires $1 million policy, Contact Lens Dispensing requires $3 million policy.

Provide completion certificates of continuing education for the years your license has been lapsed.
Max. file size: 64 MB.

If greater than 36 months, you will be required to complete the Prior Learning Assessment and Recognition [PLAR] process for special consideration [offered on-line/user pay]. If within 36 months, please forward the required number of continuing education credits for each year. Dispensing Opticians require 3 Eyeglass related certificates and 2 Related Fields per year. Contact Lens Fitters require 3 EG, 3CL and 2RF credits each year.

Did you receive formal training as a Dispensing Optician?

Yes

No

Institution

Address

Date completed:

Please provide copy of certificate / diploma received.
Max. file size: 64 MB.

Did you receive formal training as a Contact Lens Fitter?

Yes

No

Institution

Address

Date completed:

Please provide copy of certificate / diploma received.
Max. file size: 64 MB.

If you answered no, please provide details of where, when and under whose supervision (include supervisor’s qualifications) you obtained training as Dispensing Optician and/or Contact Lens Fitter.

Did you take any licensing examination(s) that assessed your skills/abilities as a Dispensing Optician?

Yes

No

If no, please explain

Date of Examination:

Name of Examining Body

Address of Examining Body

If you are applying for reinstatement of Contact Lens Fitter Certification, please answer the following questions: Did you take any licensing examination(s) that assessed your skills/abilities as a Contact Lens Fitter?

Yes

No

If no, please explain

Date of Examination:

Name of Examining Body

Address of Examining Body

Please enclose 3 letters of reference from members within your professional peer group who have worked with you within the past three (3) years.

Drop files here or

Max. file size: 64 MB, Max. files: 3.

[Fellow employees, employer, other opticians, contact lens fitters, Optometrists, optical trades….] Please include their contact information.

Please enclose 2 passport size photos, signed on reverse.

Drop files here or

Max. file size: 64 MB.

Note: Submission of this application is your personal affidavit that the information provided is true and provides the authorization required by the Dispensing Opticians Board of NL to verify your professional status by contacting your references and regulatory bodies noted on this application.

You will be notified of the Board’s decision in writing. Once accepted you will complete registration forms, pay registration fees, have professional liability insurance in place and are expected to complete continuing education requirements on annual basis. Registration period: July 1st to June 30th. You are expected to register within 3 months after your application has been approved. After that date, new application and fee will be required.

Applicant’s signature:
Max. file size: 64 MB.

Date: