Podiatrist Form 3 - Certification Of Podiatry License In Another Jurisdiction
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1
2Podiatrist Form 3
The University of the State of New York
ALL
APPLICANTS
MUST
THE STATE EDUCATION DEPARTMENT
COMPLETE THIS FORM IF
Office of the Professions
LICENSED ELSEWHERE
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF PODIATRY LICENSURE IN ANOTHER JURISDICTION
APPLICANT INSTRUCTIONS
1. Complete Section 1. Enter your name as it appears on your Application (Form 1). Be sure to sign and date item 7.
2. Send this form with any fee required to the appropriate licensing authority of the state, province or country in which you are or have been
licensed to complete Section II and return this form directly to the Office of the Professions at the address at the end of this form.
NOTE: A separate Form 3 must be received by the Department from every state, province and country in which you are or have
been licensed.
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
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
If you took a licensing examination in the United States using a different name, enter that name below:
Last ___________________________________________ First _____________________________________ Middle ______________________
6
If licensed in the United States as a podiatrist, in which jurisdiction(s) were or are you licensed or certified (list all below)
Jurisdiction: ______________________________________________________________ License number: ____________________________
Jurisdiction: ______________________________________________________________ License number: ____________________________
Jurisdiction: ______________________________________________________________ License number: ____________________________
Jurisdiction: ______________________________________________________________ License number: ____________________________
7
I request and give my permission to the licensing authority listed in item 6 above to complete the information on 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.
Podiatrist Form 3, Page 1 of 2 (Rev. 08/04)
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