Creative Arts Therapy Form 2 - Certification Of Professional Education - 2010 Page 2
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2Section II: Certification of Professional Education
Instructions to the Registrar: Please complete Parts A, B and C before sending both pages of this form in an official school envelope
directly to the Office of the Professions at the address at the end of the form. This form will not be accepted if submitted by the
applicant or any other party.
Name of applicant: ________________________________________________________________________________________________
(Section I, item 5)
Part A - Creative Arts Therapy Program Registered by the New York State Education Department (NYSED) as licensure qualifying:
To be completed only by those schools whose Creative Arts Therapy program was, at the time the applicant's degree was (or will
be) awarded, registered by the NYSED as licensure qualifying.
Completed the program on ______ / ______ / ______ and was awarded the degree/diploma of ________________________________
mo.
day
yr.
(Title of degree/diploma)
In the program area or major of _________________________________________________ on the date of ______ / ______ / ______.
(Title)
mo.
day
yr.
OR
on ______ / ______ / ______ this institution determined that the above-named student met all requirements for the degree and
mo.
day
yr.
the institution has agreed to award the degree/diploma of _____________________________________ on ______ / ______ / ______.
(Title of degree/diploma)
mo.
day
yr.
Part B - All Other Programs. An official transcript or marksheet giving courses completed by year and grades and a syllabus of the
course of studies completed must be attached.
1.
Date of applicant's entrance, and either the applicant's date of completion of studies or withdrawal from the school:
Entrance date: ______ / ______ / ______ Completion date: ______ / ______ / ______ Withdrawal date: ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
mo.
day
yr.
2.
Degree/diploma awarded: _______________________________________________________________________________________
3.
Date degree/diploma awarded: ______ / ______ / ______
mo.
day
yr.
Name of accrediting body or official organization that recognizes this program: ______________________________________________
_____________________________________________________________________________________________________________
Date of Accreditation: ______ / ______ / ______
mo.
day
yr.
Address of accrediting body or official organization that recognizes this program: ____________________________________________
_____________________________________________________________________________________________________________
PART C - Certification (To be completed by ALL schools)
I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the educational record of
the individual named on this form.
Signature of Registrar: ___________________________________________________________
Date: _______ / _______ / _______
mo.
day
yr.
Print or Type Name: ____________________________________________________________
Title or official position: __________________________________________________________
Institution: _____________________________________________________________________
Address: ______________________________________________________________________
(INSTITUTION SEAL)
City: ____________________________ State ____________ Zip Code ____________________
Telephone: _______________________________ Fax: _________________________________
E-mail Address: _________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Creative Arts Therapy Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Creative Arts Therapist Form 2, Page 2 of 2, Rev. 9/10
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