Polysomnographic Technologist Form 2 - Certification Of Professional Education - New York The State Education Department Page 2
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2Section II: Certification of Professional Education
Instructions to Registrar:
1.
Complete Part A or Part B to document the applicant’s education.
2.
Complete Part C (Certification) and return the entire form directly to the Office of the Professions at the address at the end of this form.
This form will not be accepted if returned by the applicant.
Name of Applicant: ________________________________________________________________________________________________
(Section I, item 5)
Part A - Complete this part for programs that were, at the time the degree requirements were met, registered as licensure-qualifying
by the New York State Education Department for authorization to practice as a Polysomnographic Technologist.
1.
Date of applicant's entrance, and either the applicant's date of completion of studies or withdrawal from the school:
Entrance date: ______ / ______ / ______
Completion date: ______ / ______ / ______
Withdrawal date: ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
mo.
day
yr.
2.
Type of program:
baccalaureate
associate
Other (please specify): ___________________________________________
3.
Title of degree/certificate awarded: ________________________________________________________________________________
4.
Date degree/certificate awarded: _______ / _______ / _______
mo.
day
yr.
Part B - Complete this part for programs that were, at the time the degree requirements were met, NOT registered as licensure-
qualifying by the New York State Education Department for authorization to practice as a Polysomnographic Technologist. An official
transcript or official marksheets giving courses completed by year and grades and a syllabus of the course of studies completed must be
attached.
1.
Date of applicant's entrance, and either the applicant's date of completion of studies or withdrawal from the school:
Entrance date: ______ / ______ / ______
Completion date: ______ / ______ / ______
Withdrawal date: ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
mo.
day
yr.
2.
Type of program:
baccalaureate
associate
Other (please specify): ___________________________________________
3.
Title of degree/certificate awarded: ________________________________________________________________________________
4.
Date degree/certificate awarded: _______ / _______ / _______
mo.
day
yr.
Part C - Certification
I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the
professional education of the individual named on this form.
Signature: ________________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print name: _______________________________________________________________________
Title or Official Position: _____________________________________________________________
Institution: ________________________________________________________________________
Address: _________________________________________________________________________
(SEAL)
_________________________________________________________________________
Telephone: ________________________________ Fax: __________________________________
E-mail Address: ___________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Polysomnographic Technology Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Polysomnographic Technologist Form 2, Page 2 of 2, August 2012
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