Polysomnographic Technologist Form 2 - Certification Of Professional Education - New York The State Education Department
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1
2The University of the State of New York
Polysomnographic
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Technologist Form 2
Division of Professional Licensing Services
Certification of Professional Education
Applicant Instructions
1.
Complete Section I. In item 3, enter your name exactly as it appears on your Application for Authorization (Form 1). Be sure to sign and
date item 9.
2.
Send the entire form to the institution(s) you attended and ask the registrar to complete Section II and forward all pages of the form
directly to the Office of the Professions at the address at the end of this form. Be sure to include any fee required by the institution.
This form will not be accepted if submitted by the applicant.
3.
An official transcript or official marksheets are required if you completed a program that is not registered by the Department as
licensure-qualifying at the time of your graduation.
Section I: Applicant Information
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
3.
Print Name as It Appears on Your Application for Authorization (Form 1)
Last
First
Middle
4
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
5.
Print your name as it appears on your degree or diploma.
Name: ______________________________________________________________________________________________________
6
6.
School attended: ______________________________________________________________________________________________
(Name)
(city/state or country)
7
7.
Name of degree/certificate awarded: _______________________________________________________________________________
8
8.
Date degree/certificate awarded: ________ / ________ / ________
mo.
day
yr.
9
9.
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 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
mo.
day
yr.
Polysomnographic Technologist Form 2, Page 1 of 2, August 2012
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