Occupational Therapy/occupational Therapy Assistant - Application For Licensure/authorization - The University Of The State Of New York The State Education Department - 2016 Page 2

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15. Please print clearly giving an accurate record of your educational preparation below. YOU MUST COMPLETE ALL INFORMATION FOR
15
ALL SCHOOLS/COLLEGES/UNIVERSITIES ATTENDED AND DIPLOMAS AND/OR DEGREES RECEIVED OR YOUR APPLICATION
WILL BE CONSIDERED INCOMPLETE. Attach additional sheets if necessary.
Name of High School/Secondary School or GED Diploma issuer: _____________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Graduation date: _______ / _______
or Date GED issued: _______ / _______
mo.
yr.
mo.
yr.
Professional Education:
1.
Name of School: ___________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
2.
Name of School: ___________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
3.
Name of School: ___________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
16
Yes
 No
16. Do you now hold, or have you ever held, a license or certificate to practice any profession* in any jurisdiction?
If yes, list each license/certificate, state or jurisdiction and provide appropriate information in the columns below. A Form 3 must be
submitted for each license/certificate listed unless it is a license/certificate issued by the New York State Education
Department. See the Applicant Instructions on Form 3 for specific information about completing and submitting the form.
*Profession is defined as professional titles licensed under New York State Education Law.
Date License/Certificate
License/Certificate
Limitations
Professional Title
State or Jurisdiction
Issued
Number
On License/Certificate
Occupational Therapy Form 1, Page 2 of 4, Rev. 6/16

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