Specialist Assistant Form 2 - Certification Of Professional Education - New York The State Education Department Page 2
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2SECTION II: CERTIFICATION OF PROFESSIONAL EDUCATION
INSTRUCTIONS TO INSTITUTION: Please complete Section II, sign and date the certification 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.
Please attach official transcripts, marksheets or other record giving courses completed by year and grades. The transcripts must have
the original signature of the registrar or designated official and original seal of the institution.
1.
Name of applicant:____________________________________________________________________________________________
(See Section I, item 5)
2.
Institution
(a) Name: _________________________________________________________________________________________________
(b) Address: ________________________________________________________________________________________________
(Street)
(City)
(State)
(Country)
3.
Name of program: _______________________________________________________ Length of program: _____________________
4.
Years of education and credential required for admission: _____________________________________________________________
5.
Date of applicant’s admission: _______ / _______ / _______
Date applicant completed your program _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
6.
Date certificate or degree was awarded or conferred upon the applicant: _______ / _______ / _______
mo.
day
yr.
7.
Title of credential awarded: _____________________________________________________________________________________
CERTIFICATION
NOTE: CERTIFICATION IS NOT ACCEPTABLE UNLESS DATED AND SUBMITTED AFTER THE APPLICANT’S GRADUATION.
I certify that to the best of my knowledge and belief the information in Section II is a true statement of the education record of the
individual named on this form.
Signature of Registrar or designee ________________________________________________ Date _____ / _____ / _____
Type or print name ___________________________________________________________
Title _______________________________________________________________________
(INSTITUTION SEAL)
Name of institution ____________________________________________________________
Address ____________________________________________________________________
____________________________________________________________________
Telephone ________________________________ Fax _______________________________
E-mail address ________________________________________________________________
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 2 PAGE 2 OF 2
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