Transcription of Application for Optical Establishment Permit
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Application for Optical Establishment Permit
MQA Form #OE 001, Revised 7/2020, Rule 64B29 , Page 2 of 5 Select Application type: A separate Application must be filled out for each individual Establishment . Change of ownership requires a new registration. New Optical Establishment Permit $ ( Application fee) Change of Physical Location $ (duplicate license fee) Change of Establishment Name $ (duplicate license fee) 1. Establishment AND OWNER / AGENT INFORMATIONO ptical Establishment Application for Permit Department of Health Box 6330 Tallahassee, FL 32314-6330 Fax: (850) 413-6982 Email: Do Not Write in this Space For Revenue Receipting Only Fees must be paid in the form of a cashier s check or money order, made payable to the Department of Health. Application fees and duplicate license fees are non-refundable. Name of Establishment : _____ Physical Location: (Address where the Establishment is located. This address will be posted on the Department of Health s website) _____ _____ _____ Street Suite No.
rule 64b29-1.001 mqa form # oe-001, 08-16 florida board of opticianry 4052 bald cypress way, bin #c08 tallahassee, florida 32399-3258 (850) 245-4474
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