Certification Exam Application

Certification Exam Application

Administered and processed by Scantron Corporation/Meazure Learning.
Exam Eligibility

Pathway I: Complete a NEBO approved education program, ASO College of Ocularistry, (Program is a minimum of 10,000 hours of fitting and fabricating ocular prosthetics under supervision of a BCO that is current and in good standing)

- Completion of educational program will be verified

- Letter from Sponsoring BCO proving compliance & start time

Starting in January 1, 2021, Pathway I candidates must have Graduate Diploma in possession on day of exam to be eligible. (Diploma from the American Society of Ocularistry College of Ocularistry)

Pathway II: Complete 14,000 hours experience in fitting and fabricating ocular prosthetics.

Pathway II Applicant must provide documentation showing:

- Proof of start date*

- Proof of continued work duration*

- Proof of completion of time requirement*

- At least 2 (two) referrals from an ophthalmologist/Oculoplastic surgeon

- At least 2 (two) B.C.O.s for referral

*Types of Evidence may include but are not limited to, time sheets, pay stubs, employment contacts, referral letters, tax returns, etc.

Pathway I & II also require: One (1) color copy of government issued photo ID for exam verification.
Full Name*

First Name Middle NameLast Name
Personal Phone Number (NEBO Comm. Only)*
Please enter a valid phone number.
Personal Email (NEBO Comm. Only)*
example@example.com
Date of Birth*

MonthDayYear
Date
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*
Please enter a valid phone number.
Business Email
example@example.com
Business Website Address
Country of Citizenship*

United StatesCanadaOther
Education Background
Year graduated from High School or received G.E.D?*
Name of High School
Post Secondary Education
Name of Institution
Degree & Year of Completion
Degree type, YYYY
Post Secondary Education (Optional)
Name of Institution
Degree & Year of Completion (Optional)
Degree type, YYYY
Ocularist Related Education
Have you completed the ASO College of Ocularistry? If yes = Pathway I*

YesNo
If yes, what is the date of completion?

MonthDayYear
Date
ASO ID #:
Have you completed 14,000 hours unsupervised training in the fitting and fabricating of ocular prosthetics? If yes = Pathway II*

YesNo
If yes, what is the date of completion?

MonthDayYear
Date
Work History
Current Employer/Sponsor Name Business Name Contact Phone Number Dates Employed*
Previous Employer/Sponsor Name Business Name Contact Phone Number Dates Employed
Previous Employer/Sponsor Name Business Name Contact Phone Number Dates Employed
This concludes the application for Pathway I

Please jump to the end of the application for payment and application signoff statement.

Continue for Pathway II
Pathway II Verification

Experience History
Do you engage in the fitting of ophthalmic prosthetics (artificial eyes)?

YesNo
Do you personally fabricate ophthalmic prosthetics in your laboratory? (This refers to the total fabrication process, not modification of prefabricated prostheses).

YesNo
What amount (percent) of your (average 40 hour) work week do you fit and fabricate ophthalmic prosthetics?
Percent %
How many hours (total) have you been engaged in both the fitting and fabrication of ophthalmic prosthetics? *Must provide evidence of hours
Hours
When did you begin your experience in the fitting and fabrication of ophthalmic prosthetics? *Must provide evidence of date

MonthDayYear
Date
Pathway II Verification

Work Location History
Where did you begin your experience in the fitting and fabrication of ophthalmic prosthetics? Business name, address, phone number
Work Duration
MM/DD/YYYY thru MM/DD/YYYY
Where do you presently practice the fitting and fabrication of ophthalmic prosthetics? Business name, address, phone number
Work Duration
MM/DD/YYYY thru MM/DD/YYYY
List other locations where you have accumulated experience time in both the fitting and fabrication of ophthalmic prosthetics.

*Must provide evidence for each location listed.
Additional Office/Location* Business name, address, phone number
Work Duration
MM/DD/YYYY thru MM/DD/YYYY
Additional Office/Location* Business name, address, phone number
Work Duration
MM/DD/YYYY thru MM/DD/YYYY
Have you received supervision from anyone during the accumulation of your experience time?

YesNo
If the answer above is yes, list name, address and phone number of supervisor(s) below:
Supervisor #1 Name, address, phone, email
Duration
MM/DD/YYYY thru MM/DD/YYYY
Supervisor #2 Name, address, phone, email
Duration
MM/DD/YYYY thru MM/DD/YYYY
Supervisor #3 Name, address, phone, email
Duration
MM/DD/YYYY thru MM/DD/YYYY
List three (3) ophthalmologists who are familiar with your work experience in the fitting and fabrication of ophthalmic prosthetics (whose patients you have serviced and can verify your experience time).
Name, address, phone, email
Name, address, phone, email
Name, address, phone, email
List the names of NEBO Certified Ocularists who are familiar with your work experience in the fitting and fabrication of ophthalmic prosthetics.
Name, Phone, Email
Name, Phone, Email
Name, Phone, Email
APPLICATION STATEMENT, SIGNATURE AND DATE
Because of functional limitations imposed by disability, special arrangements will be necessary for me to complete the certification examination (If yes, please send a current letter from your licensed professional stating your needs as well as other information on separate page and attach to application.)*

YesNo
Application to this examination shall be considered without discrimination as to age, sex, race, religion, sexual orientation, national origin, handicap, or marital status.

I certify that the information supplied in this application is true and accurate to the best of my knowledge.

I also acknowledge that the National Examining Board of Ocularists may refuse to accept this application, decline permission to take this examination, invalidate my scores or decline to present a certificate to me if evidence is received regarding false statements that I have made in this application, or in any other form submitted to the National Examining Board of Ocularists.

I also acknowledge that I have downloaded and read, in its entirety, the booklet entitled “Exam Candidate Handbook”, of the National Examining Board of Ocularists.

I understand that the National Examining Board of Ocularists will verify information in this application.

I grant NEBO permission to contact any sources listed in the application and authorize the release of any personal information NEBO requests. Inaccuracies in the application may result in rejection of this application and forfeiture of application fee and/or withholding of certification.
Signature*

Clear
Photo/Color Copy of Government Issued ID*

Cancelof
Documentation/Proof/Evidence*

Please consolidate into one pdf document
Cancelof
Payment may be completed below with the online payment link or a check can be mailed to NEBO 2050 Keokuk St., NEBO Suite, Iowa City, IA 52240

https://checkout.square.site/merchant/MHQP9G9GWC1G8/checkout/IIPJM3IGC6P7U4TYZV4ZGSFV
Should be Empty:

Certification Exam Application

Education Background

Ocularist Related Education

Work History

Pathway II Verification

Pathway II Verification

APPLICATION STATEMENT, SIGNATURE AND DATE