Form 3a Verification Of Medical Licensure In Another Country Page 2
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1
2Section II: Verification of Licensure
Instructions to Licensing Authority: Please complete this section and return the entire form directly to the Office of the Professions at the address
shown below. This form will not be accepted if returned by the applicant or third party.
1
Name of applicant: _______________________________________________________________________________________________________
(See item 3 on page 1)
License number: _______________________ Date issued: _______ / _______ / _______
mo.
day
yr.
Expiration of most recent registration: _______ / _______ / _______
mo.
day
yr.
2
a.
Has the applicant named in Section I been subject to any disciplinary action?
YES
NO
b.
Are any charges pending against this individual?
YES
NO
If the answer to either of these questions is "Yes," please attach relevant information.
Certification
I certify that the information shown above is true and correct, according to the records of this office.
Signature: _________________________________________________________________________________ Date: _______ / _______ / _______
Print Name: ________________________________________________________________________________
Title: _____________________________________________________________________________________
Name of Jurisdiction: ________________________________________________________________________
(LICENSING
Address: _________________________________________________________________________________
AUTHORITY
SEAL)
_________________________________________________________________________________________
Telephone: _____________________________________
Fax: ___________________________________________
E-mail Address: ____________________________________________________________________________
Return this form Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Medicine Unit,
89 Washington Avenue, Albany, NY 12234-1000.
FORM 3A, PAGE 2 OF 2
Rev. 6/15
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