Ophthalmic Dispensing Form 4 - Certification Of Trainee Experience In Ophthalmic Dispensing And/or Contact Lens Dispensing - New York The State Education Department

ADVERTISEMENT

Ophthalmic Dispensing
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Form 4
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF TRAINEE EXPERIENCE IN
OPHTHALMIC DISPENSING AND/OR CONTACT LENS DISPENSING
Applicant instructions
1.
Complete Section I in ink. Enter your name as it appears on your trainee permit. Be sure to sign and date item 5.
2.
Send this form to you supervisor(s) for them to complete Section II then forward the form directly to the Office of the Professions at the address
at the end of this form. A separate Form 4 (make copies as needed) should be submitted by each certifying supervisor.
This form will not be accepted if submitted by the applicant
SECTION I: TO BE COMPLETED BY THE TRAINEE
Birth Date
1
2
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
4
Trainee Permit Number
Print Your Name Exactly As It Appears On Your Trainee Permit
Last
First
Middle
5
I request and give my permission to the individual named below to complete Section II of this form and mail it to the New York State Education
Department and to release any other information required by the State Education Department in connection with my application for licensure.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
SECTION II: TO BE COMPLETED BY THE CERTIFYING SUPERVISOR
I certify that the applicant named above completed trainee experience in ophthalmic dispensing and/or contact lens dispensing while
supervised by me as follows:
Ophthalmic Dispensing Trainee Permit:
Dates of supervision: from ______ / ______ / ______ to ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
Contact Lens Dispensing Trainee Permit:
Dates of supervision: from ______ / ______ / ______ to ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
ATTESTATION
I declare and attest that the above statements are a true, complete, and accurate record of the trainee experience of the applicant named on
this form.
Signature of supervisor: __________________________________________________________ Date: _____ / _____ / _____
Print name of supervisor: ________________________________________________________________________________
Profession of supervisor:
Ophthalmic Dispensing
Optometry
Medicine
License number: ____________________________________________________
Employing agency or institution: __________________________________________________________________________
Address: _____________________________________________________________________________________________
Street
City
State
Zip code
Phone: ____________________________________________
Fax: ____________________________________________
E-mail: ______________________________________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Ophthalmic Dispensing
Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Ophthalmic Dispensing Form 4, Rev. 12/04

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go