Midwifery Form 2 - Certification Of Professional Education Page 2
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2SECTION II: CERTIFICATION OF PROFESSIONAL EDUCATION
INSTRUCTIONS TO REGISTRAR: Please complete Section II, sign and date the certification and return this form directly to the Office of
the Professions at the address below. 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 dean, principal, rector, registrar or designated official and original seal of the institution.
1.
Name of applicant:_________________________________________________________________________________________
(See item 5 on page 1)
2.
Institution
(a) Name: ______________________________________________________________________________________________
(b) Address: _____________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
(Country)
3.
Name of program: _____________________________________________________ Length of program: ____________________
4.
Years of education and credential required for admission: __________________________________________________________
5.
Date of admission: _______ / _______ / _______
Date of completion _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
6.
Date certificate or degree awarded or conferred: _______ / _______ / _______
mo.
day
yr.
7.
Title of credential awarded: __________________________________________________________________________________
8.
The individual named has completed a pharmacology course of not less than three semester hours or the equivalent; including
instruction in drug management of midwifery clients.
Yes
No
9.
The individual named has completed a pharmacology component, including instruction in New York State and federal laws related to
prescriptions and record keeping.
Yes
No
CERTIFICATION
Note: Certification is not acceptable unless dated and submitted after graduation.
I certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the individual
named on this form.
_______ / _______ / _______
Signature of Registrar: _________________________________________________________ Date:
mo.
day
yr.
Type or print name: ___________________________________________________________
Institution name: ______________________________________________________________
(INSTITUTION SEAL)
Address: ____________________________________________________________________
____________________________________________________________________
Telephone: __________________________ Fax: _________________________ E-mail address: __________________________
Return Directly to:
New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Midwifery Unit, 89
Washington Avenue, Albany, NY 12234-1000.
Midwife Form 2, Page 2 of 2, Rev. 02/05
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