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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HEALTH P.O. BOX 222995, CHRISTIANSTED, VI 00822-2995 VIRGIN ISLANDS BOARD OF OPTOMETRICAL EXAMINERS TEL. (340)643-8992 (STX) Dear Applicant: We have received your request for information concerning licensure to practice Optometry in the U.S. Virgin Islands. Enclosed are an application and the requirements for licensure. Please fill out the application and submit with all necessary documents to the Board. Your interest is appreciated. If we can be of further assistance, please feel free to contact us. Sincerely, Deborah Richardson-Peter, MPA Dir. Office of Professional Licensure & Health Planning For V.I. Board of Optometrical Examiners Enclosure REQUIREMENTS FOR OPTOMETRICAL LICENSURE IN THE U.S. VIRGIN ISLANDS Applications for licensure shall be sent to the VI Board of Optometrical Examiners, VI Department of Health at P.O. BOX 222995, CHRISTIANSTED, VI 00822-2995. The applicant shall comply with the following requirements: 1. Submit application on the form prescribed by and obtainable from the Secretary, Board of Optometrical Examiners. 2. Submit a recent and dated unmounted photograph of passport size of himself/herself, autographed in ink across the back. 3. Submit a chronological account of all time spent between the date of graduation from the school of optometry school and time of submitting this application. 4. Be a graduate of an Optometry Program accredited by the Accreditation Council on Optometric Education (ACOE). Copy of degree is required. 5. Be twenty-one years of age or older. Submit copy birth certificate or similar evidence as proof. 6. Two (2) current, original signed professional recommendation forms (from colleagues or licensed professionals familiar with your clinical skills). 7. All applicants must show official proof of passing the National Board of Optometric Examiners (NBEO) exam Parts I, II, III and TMOD sections. 8. Show current proof of Cardiopulmonary Resuscitation (CPR) certification for health care providers. 9. A candidate applying for licensure shall submit with his/her application the non-refundable fee of $200.00 made payable to the Government of the Virgin Islands. 10. Is not addicted to intemperate use of alcoholic stimulants or narcotic drugs. A notarized Affidavit signed by applicant attesting to the above must be furnished. 11. Submit a current (dated within 6 months of VI application) National Practitioner Data Bank self-query. A. Visit https://www.npdb.hrsa.gov/ext/selfquery/sqhome.jsp and begin the process for the self-query. Follow all instructions given. B. After your self-query has been processed by the NPDB, they will send the self-query report directly to you. C. You must first open this report to make sure that the results were not rejected, and all information submitted is correct. D. Send all parts of the self-query report directly to our office with your application. E. For NPDB questions or assistance, call 800-767-6732 or email help@npdb.hrsa.gov. - 2 - BOARD OF OPTOMETRICAL EXAMINERS FOR THE U.S. VIRGIN ISLANDS APPLICATION FOR LICENSURE Print Name ______________________ __________________ ___________________ ______ first middle last suffix Social Security # (last four digits):___________ E-Mail _______________________________________ Mobile Phone ____________________________ Mailing Address_______________________________________City___________________State _____Zip Code_______ Home Address_______________________________________City____________________State_____Zip Code_______ Birth Date______/______/________ Birthplace ________________________________ Citizen of_________________________________________________ (If you were not born in the United States, your own original certificate of Citizenship or of Declaration of Intention or of Derivative Citizenship must be submitted. Document will be returned by certified mail). High School________________________________ Location____________________________ College ____________________________________ Location____________________________ Professional School___________________________ Location____________________________ Graduation Date:________________ Degree Received:________________________________________________ *If employed, give name and address of employer Has any State rejected your application and/or revoked your professional license? (Yes or No) _____ (If “Yes” attach explanation) Have you ever been convicted of any crime or unprofessional conduct? (Yes or No) _____ If “Yes” attach explanation) *Complete the attached License Application Data Form. **New Address -3- PERSONAL SIGNATURE OF PERSONS RECOMMENDING APPLICANT This certifies that I have been personally acquainted with the applicant since the year(s) indicated opposite my name; that I believe him/her to be of a good moral character and worthy of licensure in the U.S. Virgin Islands; and that any reservations I may have about the applicant I agree to send by certified mail in a confidential letter to the Board of Optometrical Examiners of the U.S. Virgin Islands. (Signatures are required by not fewer than three citizens unrelated to applicant who must be licensed in the profession for which an applicant wishes to be examined or who are members of the staff of the professional school.) Please Print Name Personal Signature P.O. Box Address (Including street & city Known Since Return Application to: V.I. Board of Optometrical Examiners Department of Health P.O. Box 222995 Christiansted, VI 00822-2995 -4- AFFIDAVIT Note: Any false or misleading information in or in connection with any application may be cause for debarment on the ground of lack of good moral character. State of ______________________________________ ) ) ss County or City of ______________________________ ) The undersigned, being duly sworn deposes and says that he/she is the person who executed this application; that the statements herein contained are true in every respect; that he/she has never been convicted of a crime; that he/she has never been expelled from any professional society; that he/she has not suppressed any information that might affect this application; that he/she will conform to the ethical standards of conduct in his/her profession; and that he/she has read and understands this affidavit. *A crime would include either a felony or a misdemeanor. (Signature of Applicant) Sworn to before me this _____ day of____________________20______ Notary Public Commissioner of Deeds My Commission Expires on PASTE PHOTOGRAPH SECURELY IN THIS SPACE Write signature on light portion of photograph, not across features. Date of photograph VERIFICATION OF LICENSURE APPLICANT IS REQUIRED TO COMPLETE THIS SECTION OF THE FORM AND MAIL TO EACH STATE BOARD IN WHICH HE/SHE ARE NOW OR HAVE EVER BEEN LICENSED TO PRACTICE OPTOMETRY. IF NEEDED, YOU MAY MAKE ADDITIONAL COPIES OF THIS PAGE. To Whom It May Concern: I am being considered for Optometry licensure in the Territory of the U.S. Virgin Islands. The V.I. Board of Optometrical Examiners requires that this form be completed by each state in which, I am now or have ever been licensed to practice my profession. Enclosed is my authorization for release of information. Please forward this form directly to: VI Board of Optometrical Examiners, c/o Department of Health, P.O. Box 222995, Christiansted, VI 00822-2995 Applicant’s Signature Name: Address: My License No. in your State: THIS SECTION IS TO BE COMPLETED AND SIGNED BY AN OFFICIAL OF THE STATE BOARD AND RETURNED DIRECTLY TO THE VI BOARD OF OPTOMETRICAL EXAMINERS. State/Territory of: ________________________________________________________________________ Full Name of Licensee: _______________________________________________________________________________ License No.:___________________________ Issuance Date: Is license current and in good standing? If NO, furnish details. Has any disciplinary action ever been taken against the above-named Optometrist? _______ If YES, furnish details. Comments, if any: Signed: _______________________________________ BOARD SEAL Title: ________________________________________ State Board: ___________________________________ Date: -5- AUTHORIZATION FOR RELEASE OF INFORMATION In order for the Virgin Islands Board of Optometrical Examiners to assess and verify my educational background and professional qualifications, I hereby authorize the Board to:  Make inquiries concerning such information about me to my employers (past and present), institution(s) or organization(s), my references, all governmental agencies and instrumentalities (local, state, federal or foreign);  authorize the release of such information and copies of related records and documents to the Virgin Islands Board of Optometrical Examiners;  authorize the Board to disclose to such person, employers, institutions, organizations, references, governmental agencies and instrumentalities identifying and other information about me sufficient to enable the Board to make such inquiries;  release from liability all those who provide information to the Virgin Islands Board of Optometrical Examiners in good faith and without malice in response to such inquiries. Signature Date Print Name Subscribed and sworn to before me this _____day of________________________20______ Notary Public My Commission Expires -6- VIRGIN ISLANDS BOARD OF OPTOMETRICAL EXAMINERS DEPARTMENT OF HEALTH P.O. BOX 222995, CHRISTIANSTED, VI 00822-2995 NOTARIZED NON-ADDICTION AFFIDAVIT I, __________________________________________ am not addicted to the intemperate use of alcohol, illicit drugs, (first, middle, last, suffix) any prescription medications including controlled substances or any mind-altering substances that may alter or impair my judgement and ability to carry out the duties of the profession. Affidavit - NOTE: Any false or misleading information in or in connection with any application may be cause for debarment on the ground of lack of good moral character. _________________________________ _____________ Signature Date _________________________________ Print Name Subscribed and sworn to before me this ____ day of_________________ 20____ _____________________________ Notary Public _____________________ My Commission Expires -7- Virgin Islands Board of Optometrical Examiners Professional Recommendation Form February 2024 VI BOARD OF OPTOMETRICAL EXAMINERS P.O. Box 222995, Christiansted, VI 00822-2995 Tel: 340-643-8992 PROFESSIONAL RECOMMENDATION This form must be completed and mailed DIRECTLY to the VI Board of Optometrical Examiners at P.O. Box 222995, Christiansted, VI 00822-2995. VIBOE requires the completion of two (2) Professional Recommendation forms from Colleagues or Licensed Professionals who are familiar with your clinical skills and have personal knowledge of your character, personal reputation, background and professional ability. This form is confidential and required as part of the application for licensure. All elements in the section below must be completed. The lower half of the form may be used for narrative comment. This is my authorization to send this completed form and release all information in your files, favorable or otherwise directly to the VI Board of Optometrical Examiners. Applicant's Name: ______________________________________________ Profession __________________________ Applicant's Signature: ______________________________________ Date: ________________ Address:_________________________________City:______________________ State:______Zip Code: ___________ ALL ELEMENTS IN THIS SECTION MUST BE COMPLETED BY THE RECOMMENDING PROFESSIONAL The information on this form is confidential, this is NOT a public document. 1. Date and type of service: ______________________________ This individual served with me as _____________________ From____________ to __________ at______________________________________________________________________ Month/Year Month/Year Location 2. Please indicate with check mark: Poor Fair Good Superior Professional knowledge ❑ ❑ ❑ ❑ Clinical judgement ❑ ❑ ❑ ❑ Relationships with patients or clients ❑ ❑ ❑ ❑ Ethical/Professional conduct ❑ ❑ ❑ ❑ Ability to communicate ❑ ❑ ❑ ❑ Clinical skills ❑ ❑ ❑ ❑ 3. Recommendation (please indicate with a check mark): ❑ Recommend highly without reservation ❑ Recommend as qualified and competent ❑ Recommend with some reservation (explain) ❑ Concerns (explain) 4. Of particular value in evaluating the candidate is information regarding any notable strengths and weaknesses (including personal demeanor). We would appreciate your comments. If more space is needed please attach. 5. The above report is based on: (please indicate with a check mark) ❑ Close personal observation ❑ General impression ❑ A composite of evaluations ❑ Other Print Name: ____________________________________ Title: __________________________ Phone: _______________________ Signature: ____________________________________________ Date: ____________ Email: _______________________________