Specialist Assistant Form 4 - Certification Of Experience - New York The State Education Department

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The University of the State of New York
FORM 4
THE STATE EDUCATION DEPARTMENT
Office of the Professions
SPECIALIST ASSISTANT
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF EXPERIENCE
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 10.
2.
Send this form to the supervisor(s) with whom you worked to complete Section II and the certification. A separate Certificate of Experience should be
submitted by each employer.
3.
This form must be signed by the supervisor certifying your professional experience and must be returned directly to the Office of the Professions at the
address at the end of this form. Forms returned by the applicant or other parties will not be accepted.
SECTION I: APPLICANT INFORMATION
1
2
SOCIAL SECURITY
BIRTH
NUMBER
DATE
mo .
day
yr.
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT YOUR NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
Last
First
Middle
4
MAILING ADDRESS
Apt./Bldg.
Street
City
State
Zip Code
[IMPORTANT: You must notify the Department promptly of any address or name changes.]
5
Name of employer ___________________________________________________________________________________________
6
Address of employer
__________________________________________________________________________________________________________
7
Name of supervisor __________________________________________________________________________________________
8
Address of supervisor (if different from employer)
__________________________________________________________________________________________________________
9
Address of practice (if different from employer)
_________________________________________________________________________________________________________
I request and give my permission to the employer and supervisor listed in items 5 and 7 above to complete the information on this form and send any
10
documentation requested, including that requested on this form, to the New York State Education Department.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
October 2001
FORM 4 PAGE 1 OF 2

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