Form 2 - Certification Of Professional Education
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1
2FORM 2
DEPARTMENT USE ONLY
The University of the State of New York
(Bureau of Comparative Education)
THE STATE EDUCATION DEPARTMENT
Office of the Professions
PSYCHOLOGIST
Approved ______________________
Division of Professional Licensing Services
89 Washington Avenue
Date __________________________
Albany, NY 12234-1000
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1.
Complete Section I in ink.
Be sure to enter your name exactly as it appears on your New York State Licensure Application
(Form 1) and sign and date the authorization in item #10.
2.
Send this form to the Registrar or other designee of the institution you attended and ask them to complete the appropriate
parts of Section II of this form. Be sure to include any fee required. The institution completing Section II must return this form
with an official transcript directly to the Office of the Professions at the address at the end of this form. It will only be
accepted if it is submitted by the institution.
SECTION I: APPLICANT INFORMATION
1
2
SOCIAL SECURITY NUMBER
BIRTH DATE
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
Last
5
TELEPHONE/E-MAIL
First
HOME
Middle
Area code
Number
WORK
4
MAILING ADDRESS
Line 1
Area code
Number
Line 2
Line 3
E-mail
City
State
Zip Code
Country/
Province
6
Name and address of institution attended: _____________________________________________________________________________________
_______________________________________________________________________________________________________________________
7
Print name under which degree was awarded: __________________________________________________________________________________
Dates of attendance from: ______________________________ to: ______________________________
8
9
Name of degree/diploma issued: _______________________________________________________ Date awarded: _______ / _______ / _______
I request and give my permission to the institution listed in item 6 above to attach to this form an official transcript and mail it to the New York State
10
Education Department and to release any other information required by the State Education Department in connection with my application for
licensure.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
Mo.
Day
Yr.
August 2003
FORM 2, Page 1 of 2
CERTIFICATION BY INSTITUTION OFFICIAL IS TO BE MADE IN SECTION II
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