Podiatrist Form 2 - Certification Of Professional Education - New York The State Education Department
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2Podiatrist Form 2
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1.
Complete Section 1. Enter your name as it appears on your licensure application (Form 1). Be sure to sign and date item 8.
2.
Send this form to each institution where you completed your podiatrist education. Make copies as necessary. Be sure to include any fee
required by the school. The registrar, dean, principal or rector completing Section II must return this form directly to the Office of the
Professions at the address at the end of this form.
SECTION I: APPLICANT INFORMATION
1
2
SOCIAL SECURITY NUMBER
BIRTH DATE
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT YOUR FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
Last
First
Middle
4
MAILING ADDRESS
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print name under which you were registered at this professional school (if different than above): _________________________________________
6
Professional school attended: _______________________________________________________________________
Address:
7
Title of diploma: ____________________________________________
Date diploma was awarded: _______ / _______ / _______
Mo.
Day
Yr.
I request and give my permission to the school listed in item 6 above to complete Section II of this form and mail it to the New York State Education
8
Department at the address at the end of this form, and to release any other information requested by the State Education Department in connection
with my application for licensure.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
Mo.
Day
Yr.
Podiatrist Form 2, Page 1 of 2 (Rev. 08/04)
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