Psychoanalysis Form 2a - Certification Of Graduate Study

Section II: Certification of Graduate Study

Instructions to the Registrar: Please complete Section II before sending both pages of this form in an official school envelope directly to

the Office of the Professions at the address at the end of the form. This form will not be accepted if submitted by the applicant or any

other party.

Name of applicant: ________________________________________________________________________________________________

(Section I, item 5)

Master’s or Higher Degree Program

Completed the program on ______ / ______ / ______ and was awarded the degree of _______________________________________

mo.

day

yr.

(Title of degree)

on the date of ______ / ______ / ______.

mo.

day

yr.

Name of accrediting body or official organization that recognizes this program: ______________________________________________

_____________________________________________________________________________________________________________

Date of Accreditation: ____________________________________

Year

Address of accrediting body or official organization that recognizes this program: ____________________________________________

_____________________________________________________________________________________________________________

Certification

I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the educational record of

the individual named on this form.

Signature of Registrar: ___________________________________________________________

Date: _______ / _______ / _______

mo.

day

yr.

Print or Type Name: ____________________________________________________________

Title or official position: __________________________________________________________

Institution: _____________________________________________________________________

Address: ______________________________________________________________________

(INSTITUTION SEAL)

City: ____________________________ State ____________ Zip Code ____________________

Telephone: _______________________________ Fax: _________________________________

E-mail Address: _________________________________________________________________

Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,

Psychoanalysis Unit, 89 Washington Avenue, Albany, NY 12234-1000.

Psychoanalyst Form 2A, Page 2 of 2, Rev. 10/10

Psychoanalysis Form 2a - Certification Of Graduate Study - 2010 Page 2