Form 39A 1 PDF Details

In navigating the intricacies of professional licensure, international graduates seeking to practice optometry in California confront a rigorous application process, epitomized by the 39A 1 form. This document is a critical step for foreign-educated individuals aiming to provide eye care as it paves the way for board sponsorship under the stringent standards set by the California Business and Professions Code Section 3057.5 and California Code of Regulations Section 1530.1. The application mandates a non-refundable evaluation/processing fee and a thorough vetting process that includes verification of education, successful completion of the National Board of Examiners in Optometry (NBEO) exams, and an assessment of the applicant's professional conduct. This includes any past disciplinary actions or criminal convictions, which must be disclosed in detail. Additionally, the form requires particulars such as personal identification, educational background, and licensure history, if any, accentuating the comprehensive nature of the evaluation process to ensure only qualified individuals are granted the privilege to practice. Such a procedure underscores the State Board of Optometry's commitment to safeguarding public health by ensuring practitioners meet the requisite standards of knowledge and ethics necessary for service in California.

QuestionAnswer
Form NameForm 39A 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesintlgs_app foreign optometry sponsorship form

Form Preview Example

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY

GOVERNOR EDMUND G. BROWN JR.

STATE BOARD OF OPTOMETRY

2450 DEL PASO ROAD, SUITE 105, SACRAMENTO, CA 95834 P (916) 575­7170 F (916) 575­7292 www.optometry.ca.gov

APPLICATION FOR INTERNATIONAL (FOREIGN) GRADUATE SPONSORSHIP

INTERNATIONAL (FOREIGN) GRADUATES OF SCHOOLS/COLLEGES LOCATED OUTSIDE OF THE UNITED STATES (U.S.) WHERE A DEGREE FOR A PROVIDER OF EYE CARE HAS BEEN OBTAINED AND IS EQUAL TO OR GREATER THAN THAT OF A DOCTOR OF OPTOMETRY DEGREE OBTAINED IN THE U.S. FROM AN ACCREDITED SCHOOL/COLLEGE OF OPTOMETRY MAY APPLY FOR BOARD SPONSORSHIP PROVIDED THAT THEY MEET THE REQUIREMENTS OF CALIFORNIA BUSINESS AND PROFESSIONS CODE SECTION 3057.5 AND CALIFORNIA CODE OF REGULATIONS SECTION 1530.1.

 

 

 

 

 

 

 

 

 

 

PLEASE READ THOROUGHLY, THE ENCLOSED INSTRUCTIONS FOR

 

 

Total Fee Required $275.00

 

 

 

COMPLETING THE APPLICATION FOR INTERNATIONAL (FOREIGN)

 

 

 

 

 

 

 

 

 

Cashiering and Board Use Only

 

 

 

 

GRADUATE SPONSORSHIP BEFORE YOU BEGIN TO COMPLETE THE

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION FORM. MAKE YOUR CHECK PAYABLE TO THE BOARD

Receipt #

Payor ID #

Beneficiary ID #

Amount

 

 

OF OPTOMETRY. PLEASE NOTE THAT THE REQUIRED FEE IS AN

 

 

 

 

 

 

 

 

 

 

EVALUATION/PROCESSING FEE THAT IS NON­REFUNDABLE.

 

 

 

 

 

 

 

 

PLEASE ALLOW 6 – 8 WEEKS FOR PROCESSING.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please type or print clearly.

SOCIAL SECURITY NUMBER

ﾅﾅﾅ­ﾅﾅ­ﾅﾅﾅﾅ

DATE OF BIRTH (MONTH/DATE/YEAR)

ﾅﾅ/ﾅﾅ/ﾅﾅﾅﾅ

NAME (LEGAL NAME ONLY)

___________________________________

________________________

_________________________

(LAST)

(FIRST)

(MIDDLE)

Other name(s) you are known by: ________________________________________________________________

ADDRESS:

 

 

 

_____________________________________

_______________________

_________

__________

(STREET)

(CITY)

(STATE)

(ZIP CODE)

PHONE NUMBER (____) ____________________ CELL PHONE NUMBER (____) __________________

EMAIL ADDRESS:

________________________________________________________________________________________________

EDUCATION:

 

 

DATE DEGREE CONFERRED (MONTH/DATE/YEAR)

______________________________________________

ﾅﾅ/ﾅﾅ/ﾅﾅﾅﾅ

 

NAME OF SCHOOL/COLLEGE OF OPTOMETRY

 

 

 

 

LOCATION OF SCHOOL

 

 

 

 

 

_________________________________

__________

_________________

(CITY)

 

 

(STATE)

(COUNTRY)

HAVE YOU SUCCESSFULLY COMPLETED (PASSED) ALL SECTIONS (PARTS I, II, III) OF THE NBEO

 

EXAMINATION?

 

 

 

ﾅ Yes ﾅ No

PLEASE PROVIDE THE MONTH AND YEAR THAT YOU COMPLETED EACH OF THE EXAMINATIONS.

 

PART I (BASIC SCIENCE) ________

________

PART II (CLINICAL SCIENCE)

_________

________

(MONTH)

(YEAR)

 

 

(MONTH)

(YEAR)

PART III (PATIENT CARE) ________ _______

 

 

 

 

(MONTH)

(YEAR)

 

 

 

 

39A­1 Revised 7/2009

HAVE YOU SUCCESSFULLY COMPLETED (PASSED) THE CALIFORNIA LAW EXAMINATION? ﾅ Yes

ﾅ No

PLEASE PROVIDE THE MONTH AND YEAR THAT YOU COMPLETED THE EXAMINATION.

_______

_______

 

 

 

 

 

(MONTH)

 

(YEAR)

 

 

HAVE YOU PREVIOUSLY APPLIED FOR LICENSURE TO PRACTICE OPTOMETRY IN CALIFORNIA? ﾅ YES

ﾅ NO

IF YES, PLEASE PROVIDE THE MONTH AND YEAR OF THE APPLICATION:

_________

_______

 

 

 

 

 

(MONTH)

 

(YEAR)

DO YOU NOW OR HAVE YOU EVER HELD A LICENSE TO PRACTICE OPTOMETRY IN ANY OTHER STATE?

 

IF YES, PLEASE LIST EACH STATE AND LICENSE NUMBER BELOW:

 

ﾅ YES

ﾅ NO

_____________________________

__________________________

__________________________

 

 

(State)

(License #)

(State)

(License #)

(State)

(License #)

 

 

Important Notice: A letter of good standing must be sent directly to the California Board of Optometry from each State Licensing Board where you have held or currently hold a license.

HAVE YOU EVER BEEN DENIED A PROFESSIONAL LICENSE, HAD A PROFESSIONAL LICENSE PRIVILEGE SUSPENDED, REVOKED, OR OTHERWISE DISCIPLINED, OR HAVE YOU EVER VOLUNTARILY SURRENDERED ANY SUCH LICENSE IN CALIFORNIA OR ANY OTHER STATE OR TERRITORY OF THE UNITED STATES, OR BY

ANY OTHER GOVERNMENTAL AGENCY?

ﾅ YES

ﾅ NO

If YES, attach your detailed explanation of the circumstance surrounding the arrest/conviction or disciplinary proceedings taken by another state or governmental agency and attach any documentation (i.e., arrest report/court documents/accusations) that you may have.

HAVE YOU EVER BEEN CONVICTED OF, PLED GUILTY TO, OR PLED NOLO CONTENDERE TO ANY

 

MISDEMEANOR OR FELONY?

ﾅ YES

ﾅ NO

If YES, attach your explanation and related documents as described in the REPORTING PRIOR CONVICTION(S) section of the instructions. You must disclose all convictions even if previously reported to the Board. However, it is not necessary for you to re­submit documentation previously on file, you may simply provide a written statement indicating that you believe the information is already on file.

(Convictions dismissed under Section 1203.4 of the Penal Code must be disclosed. You need not include offenses prior to your 18th birthday. You may omit traffic infractions under $300 that did not involve alcohol, dangerous drugs, or controlled substances.

I declare under penalty of perjury under the laws of the State of California that all the information submitted on this form and on any accompanying attachments submitted is true and correct.

________________________________________________

_________________________________

Signature of Applicant

Date

ATTACH ONE 2 X 2 COLOR PHOTOGRAPH TAKEN OF YOU WITHIN THE LAST 60 DAYS.

ATTACH COLOR PHOTO

HERE

PHOTO IS TO BE HEAD

AND SHOULDERS ONLY

And of

PASSPORT QUALITY

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1. The Form 39A 1 will require certain details to be inserted. Make certain the following blanks are finalized:

Stage # 1 for submitting Form 39A 1

2. Your next step would be to fill out the following blank fields: NAME LEGAL NAME ONLY Other names, MONTH YEAR, PART II CLINICAL SCIENCE, Yes No, MONTH YEAR, MONTH YEAR, and A Revised.

Filling out segment 2 of Form 39A 1

Always be very careful while completing MONTH YEAR and Yes No, because this is where many people make some mistakes.

3. Completing HAVE YOU SUCCESSFULLY COMPLETED, MONTH, YEAR, State, License, YES NO, License, State, License, HAVE YOU PREVIOUSLY APPLIED FOR, YES NO, and YES NO is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Stage no. 3 in submitting Form 39A 1

4. To move ahead, this fourth stage requires completing several blanks. Included in these are HAVE YOU PREVIOUSLY APPLIED FOR, Signature of Applicant, Date, ATTACH ONE X COLOR PHOTOGRAPH, ATTACH COLOR PHOTO, HERE, PHOTO IS TO BE HEAD AND SHOULDERS, And of, and PASSPORT QUALITY, which you'll find vital to going forward with this particular document.

Form 39A 1 conclusion process described (portion 4)

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