Occupational Therapy Form 2 - Certification Of Professional Education - New York The State Education Department

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FORM 2
(check one)
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Occupational Therapist
Division of Professional Licensing Services
Occupational Therapy Assistant
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1.
If your professional program is not accredited by the American Occupational Therapy Association, (most schools located outside
the United States are not accredited) do not use this form. See ‘Education Requirements’ for further instructions.
2.
If you graduated from a New York State registered licensure-qualifying program or an AOTA accredited program, complete Section I in ink.
Enter your name as it appears on your Application for Licensure/Authorization (Form 1). Be sure to sign and date item 8.
3.
Send this form to the institution you attended and ask the Registrar to complete the appropriate parts of Section II of this form. Be sure to
include any fee required. The institution completing Section II must forward it directly to the Office of the Professions at the address at the
end of this form. The Office of the Professions will not accept this form unless it is submitted directly by the institution in an official school
envelope.
SECTION I: APPLICANT INFORMATION
1
2
Social Security Number
Birth Date
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Your Name Exactly As You Wish It To Appear On Your Permit
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 your degree/diploma was awarded: __________________________________________________________________
Professional school attended: _________________________________________________________________________________________
6
Address: _________________________________________________________________________________________________________
7
Title of diploma or degree: _________________________________________ Date diploma or degree was awarded: _______ / _______ / ______
mo
day
yr.
I request and give my permission to the institution(s) listed in item 6 above to provide any information requested, including that requested on this
8
form, to the New York State Education Department.
__________________________________________________________________________
________________________________
Applicant's signature
Date
Occupational Therapy Form 2, Page 1 of 2, Rev. 2/12

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