Form 2 - Certification Of Professional Education - The State Education Department

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The University of the State of New York
Nurse Form 2 (Check one)
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Registered Professional Nurse
Division of Professional Licensing Services
Licensed Practical Nurse
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1.
Do not use this form if your nursing school is located outside the United States. (See Verifying Education Credentials from Non-U.S.
Programs under Education Requirements.)
2.
Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 8.
3.
Have the school you attended that made you eligible to take the NCLEX examination complete the appropriate parts of Section II. If you
graduated from a New York State licensure qualifying nursing education program after April 1, 1998, you do not need to submit this
form. Be sure to include any fee required by the school. The registrar must return the entire form in an official school envelope directly to the
Office of the Professions at the address at the end of this form. This form will not be accepted if submitted by you.
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 Your Name Exactly As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
Mailing Address
(You must notify the Department promptly of any address or name changes.)
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print your name as it appears on your degree or diploma: _________________________________________________________________________
6
Secondary institution attended: ______________________________________________________________________________________________
7
Nursing school attended: __________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________________
Dates of attendance from ______ / ______ / ______ to ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
8
I request and give my permission to the school listed in item 7 above to complete Section II of this form and mail it to the New York State Education
Department at the address at the end of this form, and to release any other information requested by the State Education Department in connection
with my application for licensure.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Nurse Form 2, Page 1 of 2, Rev. 10/13

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