Trade Name Transfer Form

Per K.A.R. 65-9-4. Transfer. (a) The approval to use a trade or assumed name shall not be transferable except with the approval of the board.

(b) Any applicant seeking to transfer the approval for the use of a trade or assumed name to another licensee which is authorized to engage in the practice of optometry in this state shall file a completed application with the secretary-treasurer on a form prescribed by the board.

(c) If the transfer is approved, the transferee shall become responsible for compliance with the applicable requirements of K.A.R. 65-9-1, et seq.

Transferor Name:

Transferor Phone Number

Transferee Name:

Transferee Phone Number

Transferor License Number

Transferor Email

Transferee License Number

Transferee Email

Trade Name to be Transferred:

Location(s)

Licensee(s) who will practice under the trade name

Do you intend to practice or are you currently practicing under the name of a professional corporation or professional limited liability company authorized by either KSA 17-2706 or KSA 17-7668? If yes, provide the name of the entity, the owners of the entity (shareholders or members) and all licensees practicing under the name of the entity. Also, provide a copy of the draft or filed articles of incorporation or articles of organization.

Yes
No

Name of Entity

Articles of Incorporation

SIGNATURE OF Transferor and Transferee. Each person listed above must provide an electronic signature by typing their name below.

By signing and submitting the foregoing application, I verify under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.

Transferor Signature

Transferee Signature

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