Midwifery Form 2 - Certification Of Professional Education

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The University of the State of New York
Midwife Form 2
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 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. Be sure to include any fee required by the institution. A separate
Certification of Professional Education must be submitted for each educational program attended.
SECTION I: APPLICANT INFORMATION
1
2
Social Security
Birth
Number
Date
mo .
day
yr.
(Leave this blank if you do not have 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 (You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print name under which certificate or degree was awarded: ___________________________________________________________
6
Professional 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, to the New York State Education Department.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Midwife Form 2, Page 1 of 2, Rev. 02/05

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