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Clinical Nurse Specialist Form 1 - Application For A Clinical Nurse Specialist Certificate - 2016 Page 3

13. Gender and Ethnicity (This item is optional)

Information on gender and ethnicity is sought solely to allow the New York State Education Department to collect and analyze data

concerning diversity in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and

program evaluation purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for

licensure.

Gender

Male

Female

Ethnicity

White (not Hispanic)

Black (not Hispanic)

Asian

Hispanic

Native American

14. Citizenship/Immigration Status

Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses,

registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation,

you must complete this section of this form and check the appropriate box below which indicates your citizenship/immigration status.

I am:

A United States citizen or National.

An alien lawfully admitted for permanent residence in the United States.

An alien granted asylum under Section 208 of the Immigration and Nationality Act.

A refugee granted asylum under Section 207 of the Immigration and Nationality Act.

An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1

year.

An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.

An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April

1980.

Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not

required to have a Visa to enter the United States

I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or

similar relief from deportation. Please specify

I do not reside in the United States.

If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship

and Immigration Services (USCIS):

USCIS number

QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL

LAW SHOULD BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283,

OR VISIT THEIR WEB SITE AT

Clinical Nurse Specialist Form 1, Page 3 of 4, Revised 6/17

Clinical Nurse Specialist Form 1 - Application For A Clinical Nurse Specialist Certificate - 2016 Page 3