Midwifery Form 2a - Certification Of Pharmacology Course Or The Equivalent Of Not Less Than Three Semester Hours - New York The State Education Department
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1
2Midwife Form 2A
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 PHARMACOLOGY COURSE OR THE EQUIVALENT
OF NOT LESS THAN THREE SEMESTER HOURS
APPLICANT INSTRUCTIONS
Note: Use this form only If you graduated prior to December, 1995 and did not complete the pharmacology course at the same institution that you
completed your New York State registered, licensure qualifying midwifery program.
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 7.
2.
Send this form to the institution where you completed a pharmacology course, including instruction in drug management of midwifery clients for
completion of Section II. Be sure to include any fee required.
SECTION I: APPLICANT INFORMATION
Social Security
Birth
1
2
Date
Number
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
Mailing Address (You must notify the Department promptly of any address or name changes.)
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print name under which program was completed: __________________________________________________________________
(If different from above)
6
Name of institution: __________________________________________________________________________________________
Dates of attendance:
from __________ / __________ / __________ to __________ / __________ / __________
mo.
day
yr
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
7
documentation requested, including that requested on this form, to the New York State Education Department.
Applicant's signature: __________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Midwife Form 2A, Page 1 of 2, Rev. 02/05
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