Occupational Therapy/occupational Therapy Assistant - Application For Licensure/authorization - The University Of The State Of New York The State Education Department - 2016 Page 4
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421. Gender and Ethnicity: (This item is optional.)
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Information on gender and ethnicity is sought solely to allow the 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.
Male
Gender:
Female
White (not Hispanic)
Ethnicity:
Black (not Hispanic)
Asian
Hispanic
Native American
21
22. Education Program Review
I give permission to the New York State Education Department to release my examination results to my professional school for the
confidential purposes of program review and institution research and planning. I may rescind this authority at any time by notifying the
Division of Professional Licensing Services in writing.
Yes
No
Please initial: _____________________
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23. Affidavit With Acknowledgment (Notarization required.)
Applicant
I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I
understand that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure
and may result in criminal prosecution. This form must be signed and dated in the presence of a Notary Public.
Signature of the applicant: ______________________________________________________________________________________
Date __________ / __________ / __________
Month
Day
Year
Notary
State of __________________________________________________ County of __________________________________________
On the ____________ day of ______________________ in the year __________ before me, the above signed, personally appeared
__________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual
Applicant Name
whose name is subscribed to this application and acknowledged to me that he/she executed the application and swore that the
statements made by him/her in the application and all supporting materials are true, complete, and correct.
Notary Public signature _________________________________________________________________________________________
Notary ID number _______________________________
Notary Stamp
Expiration date __________ / __________ / __________
Month
Day
Year
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY
12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Occupational Therapy Form 1, Page 4 of 4, Rev. 6/16
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