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SECTION II: CERTIFICATION OF EXPERIENCE

INSTRUCTIONS TO SUPERVISOR: Please complete Section II, sign and date the certification in the presence of a Notary Public and

return this form directly to the Office of the Professions at the address at the end of this form. This form will not be accepted if incomplete

or if returned by the applicant or any other party.

Name of applicant ____________________________________________________________________________________________

Dates you supervised applicant

Beginning date _______ / _______ / _______

Ending date _______ / _______ / _______

Duties of applicant (attach additional sheets if needed)

___________________________________________________________________________________________________________

CERTIFICATION

I certify that to the best of my knowledge and belief the information in items 5-9 of Section I and Section II are true

statements of the experience record of the individual named on this form.

Signature of supervisor __________________________________________________________ Date _____ / _____ / _____

Type or print name ___________________________________________________________

License number _____________________ Jurisdiction licensed in _____________________

Address ____________________________________________________________________

____________________________________________________________________

Telephone __________________________ Fax _____________________________________

E-mail address _______________________________________________________________

NOTARY CERTIFICATION OF IDENTIFICATION (Certification by Notary Public is Required.)

State of __________________________________________ County of _______________________________________

I certify that on the date set forth below the individual named above did appear personally before me and that I did identify this applicant by: (a) comparing

his/her physical appearance with the photograph on the identifying document presented by the applicant and with the photograph affixed hereto, and (b)

comparing the applicant's signature made in my presence on this form with the signature on his/her identifying document. The statements on this

document are subscribed and sworn to before me by the applicant on this __________ day of ____________________, __________.

Notary Public signature _____________________________________________________________________________

Notary ID number ____________________________

Expiration date __________ / __________ / __________

Month

Day

Year

New York State Education Department, Office of the Professions, Division of Professional Licensing

RETURN DIRECTLY

Services, Specialist Assistant Unit, 89 Washington Avenue, Albany, New York, 12234-1000.

TO:

October 2001

FORM 4 PAGE 2 OF 2

Specialist Assistant Form 4 - Certification Of Experience - New York The State Education Department Page 2

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