Optometry Form 2 - Certification Of Professional Education - New York The State Education Department
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1
2The University of the State of New York
Optometry Form 2
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1. Complete Section I in ink. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 9.
2. Send this form to the professional optometry school(s) you attended and ask the registrar(s) to complete the appropriate parts of Section II and
forward the form directly to the Office of the Professions at the address at the end of the form. This form will not be accepted by the Office of the
Professions if submitted by the applicant. Be sure to include any fee required by the school. A separate Form 2 should be submitted for
each professional educational program you attended.
3. An official transcript or marksheets are required if you completed a program that is not registered by the Department as licensure qualifying or
accredited by the American Optometric Association Council on Optometric Education (AOACOE).
Section I: Applicant Information
Birth Date
1
2
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Name Exactly As It Appears On Your Licensure Application (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
If different from above, print exact name under which your degree was awarded:
_____________________________________________________________________________________________________________________
6
High School attended: ___________________________________________________________________________________________________
7
Postsecondary/Preprofessional institution attended: ___________________________________________________________________________
8
Professional school attended: ____________________________________________________________________________________________
Date of degree: _______ / _______ / _______
mo.
day
yr.
I request and give my permission to the school listed in item 8 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.
Optometry Form 2, Page 1 of 2, Rev. 08/05
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