Occupational Therapy Form 2 - Certification Of Professional Education - New York The State Education Department Page 2
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2SECTION II : CERTIFICATION OF EDUCATION
INSTRUCTIONS TO THE REGISTRAR:
1.
Use this form to verify professional education from a New York State registered licensure-qualifying or AOTA accredited program.
2.
Complete Parts A and B and return this form directly to the Office of the Professions at the address at the end of this form in an official school
envelope. Do not return this form to the applicant.
PART A
– PROGRAM COMPLETED:
The applicant named below completed an occupational therapy or occupational therapy assistant program that was, at the time the degree
requirements were met, either:
•
Registered as licensure qualifying by the New York State Education Department,
AND/OR
•
Accredited by the American Occupational Therapy Association.
It is certified that ______________________________________________________________________________________________________:
(Name of applicant – See Section I, item 5)
met all requirements for the degree/diploma of _______________________________________________ on ________ / ________ / ________
mo.
day
yr.
(Title of degree/diploma)
was awarded the degree/diploma of _______________________________________________________ on ________ / ________ / ________
mo.
day
yr.
(Title of degree/diploma)
PART B
- CERTIFICATION:
This form will not be accepted if the date below precedes the date when the degree was awarded.
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 or designee_____________________________________________________________ Date _______ / _______ / _______
mo.
day
yr.
Type or print name ________________________________________________________________
Title or official position _____________________________________________________________
Institution ________________________________________________________________________
(SEAL OF INSTITUTION)
Address _________________________________________________________________________
__________________________________________________________________________
Telephone number ______________________________ Fax _______________________________
E-mail ___________________________________________________________________________
RETURN DIRECTLY
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
TO:
Occupational Therapy Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Occupational Therapy Form 2, Page 2 of 2, Rev. 2/12
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