Occupational Therapy/occupational Therapy Assistant - Application For Licensure/authorization - The University Of The State Of New York The State Education Department - 2016 Page 3
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417. Have you taken the examination given by the National Board of Certification in Occupational Therapy? Yes
No
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Date of examination: ______ / ______ / ______
mo.
day
yr.
Exam Score: ___________________
Date certified: ______ / ______ / ______
mo.
day
yr.
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19. Child Support Obligation
Everyone applying for a professional license, permit, or registration, or any renewal thereof, must file a written statement that, as of the
date of the filing, she or he is, or is not, under an obligation to pay child support*. Individuals who are four months or more in
arrears in child support or who have failed to comply with a summons, subpoena or warrant relating to a paternity or child
support proceeding may be subject to suspension of their business, professional, drivers and/or recreational licenses and
permits. The intentional submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of
support obligations is punishable under section 175.35 of the Penal Law.
You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance
with their obligation to pay child support can be issued a credential for no more than six months in order to comply with their child
support obligations.
Check only A or B below. If you check B, you must check one of the five statements listed below it.
A. I am not under an obligation to pay child support
OR
B. I am under an obligation to pay child support and (please check only one of the following)
I am current and am not four months or more in arrears in the payment of child support; or,
I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or,
The child support obligation is the subject of a pending court proceeding; or,
I am receiving public assistance or supplemental security income; or,
None of the above four statements apply.
* New York State General Obligations Law, section 3-503.
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20. 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.
A United States citizen or National.
B.
An alien lawfully admitted for permanent residence in the United States.
C.
An alien granted asylum under Section 208 of the Immigration and Nationality Act.
D.
A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
E.
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.
F.
An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
G.
An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April
1980.
H.
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.
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: _______________________________________
J.
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
Occupational Therapy Form 1, Page 3 of 4, Rev. 6/16
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