Form 3b - Verification Of Pre-1972 Medical Licensure In Another U.s. State Or Territory

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FOR ENDORSEMENT OF PRE-1972
FORM 3B
The University of the State of New York
U.S. STATE LICENSES ONLY
THE STATE EDUCATION DEPARTMENT
MEDICINE
Office of the Professions
OSTEOPATHIC MEDICAL
Division of Professional Licensing Services
LICENSES
89 Washington Avenue
Albany, NY 12234-1000
STATE MEDICAL LICENSES
VERIFICATION OF PRE-1972 MEDICAL LICENSURE IN ANOTHER U.S. STATE OR TERRITORY
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 7.
2. Please send this form to the appropriate U.S. state or territory where you passed a pre-1972 state or territory licensure examination. Be sure to
include any fee required.
The licensing authority of that jurisdiction must fully complete Section II and return the form directly to the Office of the
Professions at the address at the end of this form.
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 FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1):
Last
First
Middle
Apt./Bldg.
4
MAILING
ADDRESS:
Street
City
State
Zip Code
Province/Country
If not U.S.
5
If you took a licensing examination in the United States, using a different name, enter that name below:
_________________________________________________________________________________________________________
(Last)
(First)
(Middle)
6
Indicate the United States state or territory where you were licensed by a pre-1972 state or territory examination:
______________________________________________________________________________________________________________
Date license was issued ____ / ____ / ____
License number: _______________________________________
7
I request and give my permission to the licensing authority listed in item 6 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.
September 2002
FORM 3B, PAGE 1 OF 2

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