Form 3a Verification Of Medical Licensure In Another Country
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1
2NOTE: Licensure in another
FORM 3A
The University of the State of New York
jurisdiction is not a requirement for
THE STATE EDUCATION DEPARTMENT
licensure in New York State;
MEDICINE
Office of the Professions
however, we require verification of
Division of Professional Licensing Services
current status from every
jurisdiction in another country in
which you have been licensed and/or
practiced within the past five years.
Verification of Medical Licensure in Another Country
Applicant Instructions
1. Complete Section I. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 6.
2. Send this form to each licensing authority in another country where you have been licensed and have practiced within the past five years.
Request that they complete Section II below and return this form directly to the Office of the Professions at the address at the end of this form.
Be sure to include any fee(s) required. If additional forms are needed, please photocopy this form. Verifications must be in English or otherwise
submitted with an official translation. We will not accept this form if submitted by the applicant or a third party.
Section I: Applicant Information
2
1
Birth Date
Social Security Number
Month
Day
Year
(Leave this blank if you have no U.S. Social Security Number)
3
Print Full Name Exactly as It Appears on Your Application for Licensure (Form 1)
Last
First
Middle
4
Mailing Address:
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print name of jurisdiction and country ______________________________________________________________________________________
Name under which you are licensed in that jurisdiction and country ______________________________________________________________
Date of Licensure _______ / _______ / _______ License Number ________________________________
mo.
day
yr.
6
I request and give my permission to the licensing authority listed in item 5 above to complete the information on this form and mail it to the New
York State 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.
Rev. 6/15
FORM 3A, PAGE 1 OF 2
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