Form 2 - Certification Of Professional And Preprofessional Education
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1
2FORM 2
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
MEDICINE
Office of the Professions
CERTIFICATION OF PROFESSIONAL AND PREPROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
Use this form only if you attended a New York State registered or LCME/AOA accredited medical school.
1.
Send this form to the professional school you attended to complete Section II. Be sure to include any fee required.
2.
If you attended a medical school that has been closed, send this form to the official repository of the records for that school (e.g., SEESCYT).
3.
This form must be signed by the Registrar of the medical school and sent back directly to the Office of the Professions by that school official in an
official school envelope to the address at the end of this form. This form will not be accepted if returned by the applicant or any other 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)
Print Full Name Exactly as It Appears on Your Application for Licensure (Form 1),
3
Or Application for Limited Permit (Form 5B)
Last
First
5
Telephone/E-Mail
Middle
Daytime Phone
4
Mailing Address:
(You must notify the Department promptly of any address or name changes.)
Area Code
Phone Number
Line 1
E-Mail Address (Please print clearly)
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
Print name under which your degree or diploma was awarded (
___________________________________________________
if different from above) :
7
Professional School Attended: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________________________
8
Name of Degree/Diploma: ____________________________________________________ Date awarded: ________________________________
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
9
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.
Rev. 4/15
Form 2, page 1 of 2
CERTIFICATION BY PROFESSIONAL SCHOOL OFFICIAL IS TO BE MADE ON NEXT PAGE
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