A. New Jersey Disciplinary Actions (Required)
A checked box will indicate if the New Jersey State Board of Medical Examiners or the New Jersey State Board of Optometrists has taken any action against your license within the past 10 years. (Do not click in the boxes.)
- Review any preprinted data.
- If data is incorrect or incomplete, click on the box.
B. Out-of-State License Actions/Restrictions (Required)
- Read the question referring to any actions taken against you as a result of professional misconduct proceedings by any other state or licensing entity within the past 10 years.
- Respond to question by clicking in the 'Yes' or 'No' button. (Click again to de-select).
- If you answered 'Yes', list the following data:
Date of Action Taken Enter date (Example: 03-24-2001)
Action Taken Enter text (30 character limit)
Licensing Agency or State Enter the State and/or Department.
Under appeal Click on the box.
- To add an additional out-of-state licensee action, click on 'Click here to add additional Out-of-State Licensee Actions' button and proceed as above. (You may add multiple actions.)
When finished, click one of the buttons at the bottom of the screen:
- Save & go to previous page
- Save & stop for now
- Save & go to next page