Massage Therapy Form 2 - Certification Of Professional Education - New York The State Education Department
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1
2
3Massage Therapist Form 2
The University of the State of New York
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 1 in ink. Enter your name as it appears on your application (Form 1) and be sure to sign and date item 9.
2.
Send this form to the educational institution you attended to complete Section II. Be sure to include any fee required by the institution. They
must forward it directly to the Office of the Professions at the address at the end of this form.
SECTION I: APPLICANT INFORMATION
Social Security
Birth
1
2
Number
Date
mo .
day
yr.
(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
5
TELEPHONE/E-MAIL
First
Middle
Daytime Phone
4
Area Code
Phone Number
Mailing Address (You must notify the Department promptly of any name or address changes.)
E-Mail Address (Please print clearly)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
Print name under which your degree/diploma was awarded: __________________________________________________________________
7
Name of massage therapy school attended: ______________________________________________________________________________
Address: _________________________________________________________________________________________________________
Name of degree/diploma: _____________________________________________ Date degree/diploma was awarded: ______ / ______ / ______
8
mo.
day
yr.
I request and give my permission to the school listed in item 7 above to complete the information on this form and send any documentation
9
requested by the NYS Education Department including that listed on page 2 of this form (e.g. an official transcript) to the New York State Education
Department.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Massage Therapist Form 2, Page 1 of 3, (REV. 07/04)
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