VISION CERTIFICATE

GENERAL
Initial examination is required, with or without corrective lenses, to prove (1) near vision acuity of Snellen English or
equivalent Jaeger J1 at 1! inches" (!) far vision acuity of !#$%# or &etter and (') color perception test for red$green and
&lue$yellow differentiation(
)or annual recertification, the examination is required to prove near vision acuity or Snellen English or equivalent Jaeger
J1 at 1! inches( *his certificate is valid for + months only from the date of eye test(
This certifcation will be valid only if signed by one of the following:
Optometrist Medical doctor Registered nurse Certifed Physician's
ssistant
!"T#!"T$TC$%a &evel ''' "!' "()*+*, &evel '''
APPLICANT INFORMATION (*o &e completed &y ,andidate)
,andidate
-ame.
SE/0S*I0- 10JES2
3ate of
eye test
!%$1!$!#1!
,andidate
Signature.
TEST/EXAMINATION RESULTS (*o &e completed &y 3octor $ Examiner)
4eets 5ithout Eye ,orrection 4eets 5ith Eye ,orrection
(1) )ar 6ision 7 !#$%# 4inimum
(!) -ear 6ision Jaeger J1 letters at 1! inches
(') ,olor 8erception 8seudoisochromatic 8lates
(a) 1ed$9reen 3ifferentiation
(&) /lue$:ellow 3ifferentiation
;;;;
,omments.

DOCTOR / EXAMINER INFORMATION (*o &e completed &y 3octor $ Examiner)
I administered the vision examination(s) to the applicant$candidate
*he examiner<s professional title is.
=ptometrist 4edical 3octor 1egistered -urse
,ertified 8hysician<s 0ssistant 0S-*$S-**,1a >evel III 0-SI -%?(!(+ >evel III
-ame of the 3octor$ Examiner with stamp .
8==1-04 @I1A/20@01
Signature of 3octor $ Examiner.
8rofessional 0ddress.
*E,-I4=-* J9, J6 6I>>09E
20/S20- ? 81=JE,*
0/A 320/I, A(0(E
*elephone -um&er. BCD1 ?+ +EDC%+E State >icense -um&er.