Form 2 - Certification Of Professional Education Page 2
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1
2SECTION II : CERTIFICATION OF PROFESSIONAL EDUCATION – TO BE COMPLETED BY THE INSTITUTION OFFICIAL
INSTRUCTIONS TO INSTITUTION OFFICIAL:
1.
Complete Part A to document the applicant’s education.
2.
Complete Part B to document the applicant’s required internship (if applicable).
3.
Complete Part C (certification) and return this form with an official transcript documenting completion of the doctoral program directly to the
Office of the Professions at the address at the end of this form. Do not return this form to the applicant.
PART A
– PROGRAM COMPLETED:
1.
It is certified that ________________________________________________________________________ completed a psychology doctoral program
(Name of applicant-See Section I, item 7)
in _______________________________________________ that was, at the time the degree requirements were met:
(Specialty area)
registered as licensure qualifying by the New York State Education Department.
accredited by the American Psychological Association (APA) at date of graduation.
a program not registered by New York State as licensure qualifying or accredited by the APA
2.
This program awards the degree of:
Ph.D.
Psy.D.
Ed.D.
Other ______________________________
3.
The applicant named above:
met all requirements for the degree including the dissertation on ________ / ________ / ________
mo.
day
yr.
was awarded the degree on ________ / ________ / ________
mo.
day
yr.
4.
For programs not registered as licensure qualifying by New York State, please provide the following information:
Official program title ___________________________________________ Specialty: __________________________________________________
Is this doctoral program offered by the university psychology department(s)?
YES
NO
(a) If no, which department offered the degree program? _____________________________________________________________
(b) If no, please explain in a separate attachment the relationship of this program to the psychology department(s) program(s).
(c)
Does this program prepare students for the practice of psychology?
YES
NO
PART B
– REQUIRED INTERNSHIP, FIELD EXPERIENCE or APPLIED RESEARCH (if applicable):
Location of approved internship, field experience or applied research:
Facility name ___________________________________________________________________________________________________________
Address _______________________________________________________________________________________________________________
City ______________________________________________________________ State __________ Zip code____________________________
Phone _____________________________ Fax _____________________________ E-mail ___________________________________________
Dates of approved year-long internship (or equivalent), field experience or applied research: From: _____ / _____ / _____ To _____ / _____ / _____
mo.
day
yr.
mo.
day
yr.
PART C
– CERTIFICATION:
This form will not be accepted if the date below precedes the date when the degree was awarded.
I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the educational record of the
individual named on this form.
Signature of Registrar ______________________________________________________________ Date _______ / _______ / _______
mo.
day
yr.
Type or print name ________________________________________________________________
Institution ________________________________________________________________________
(SEAL OF INSTITUTION)
Address _________________________________________________________________________
__________________________________________________________________________
Telephone number ______________________________ Fax _______________________________
E-mail ___________________________________________________________________________
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
RETURN DIRECTLY
Psychology Unit, 89 Washington Avenue, Albany, NY 12234-1000.
TO:
FORM 2, PAGE 2 OF 2
August 2003
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