Specialist Assistant 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
FORM 2
THE STATE EDUCATION DEPARTMENT
Office of the Professions
SPECIALIST ASSISTANT
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 8.
2.
Send this form to the institution(s) you attended for completion of Section II and the certification. Be sure to include any fee required by the institution. A
separate Certification of Professional Education should be submitted for each educational program you attended.
3.
This form must be signed by the registrar or other appropriate official of the institution and returned directly in a sealed school envelope 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
Print name under which certificate or degree was awarded: ___________________________________________________________
6
School attended: ____________________________________________________________________________________________
7
Title of certificate or degree: ______________________________________________ Date awarded: _______ / _______ / _______
mo.
day
yr.
I request and give my permission to the institution listed in item 6 above to complete the information on this form and send any documentation
8
requested, including that requested on this form (e.g. an official transcript),to the New York State Education Department.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
October 2001
FORM 2 PAGE 1 OF 2
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