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Replacement License Wall Certificate for Lost, Destroyed, Damaged or Name Change

Any licensee who loses, destroys, damages or has a name change may obtain a replacement original wall certificate (8.5 x 11) for a fee of $12.00.   

Name Changes - In order for the Board to change the legal name in which your Optometry license was originally issued, you are required to submit one of the following: a marriage certificate specifying the name change following marriage; a divorce or dissolution of marriage decree specifying the name change, or other court order specifying the name change.  Merely copy the document and fax, scan and email, or mail the copy to the Board office. Board staff will update your individual record once the official documentation is received.  You must have an accurate license certificate posted in your office for the public to validate your official name and license.  Current public information must correspond to the name and practice locations provided on the board’s website. 

Complete this form to be mailed with any documentation and the fee to the board office.  
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