Podiatrist Form 3 - Certification Of Podiatry License In Another Jurisdiction Page 2

ADVERTISEMENT

SECTION II : CERTIFICATION OF LICENSURE
INSTRUCTIONS TO LICENSING AUTHORITY:
Please complete this section and return this 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. Attach additional sheets if necessary.
1.
Name of applicant
: ________________________________________________________________________________________________
2.
Profession in which applicant is licensed in your state: _________________________________________________________
3.
License number: ___________________________________________ Date of licensure: ________ / ________ / ________
mo.
day
yr.
4.
Jurisdiction issuing original license or certification: ____________________________________________________________
5.
Is the individual currently licensed or registered?
Yes
No If Yes, Date of expiration:
________ / ________ / ________
mo.
day
yr.
6.
Please indicate if the license was issued under any of the following special conditions (check all that apply):
Endorsement of licensure in another jurisdiction (please identify: ______________________________________)
Waiver of examination
Waiver of education
Other (please attach explanation)
7.
If the license was issued based on a written examination, please indicate the examination title, date and score (eg. PM/LEXIS;
Written State Examination, Other – please describe.):
Examination title _____________________________________________
Date _____ / _____ / _____ Score ________________
mo.
day
yr.
Examination title _____________________________________________
Date _____ / _____ / _____ Score ________________
mo.
day
yr.
8.
Did the issuance of this license involve any practice limitations?
Yes
No
9.
Was there ever any disciplinary action against this license?
Yes
No
(If the answer to this question is yes, please describe in detail and attach.)
10. Are there any disciplinary charges pending against this license or has he/she surrendered a license to
Yes
No
avoid disciplinary charges?
CERTIFICATION
I certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the licensing
status and examination results of the applicant named on this form. I further certify that, other than those listed above or attached, this
licensing authority has never taken any disciplinary action against this person and that, in so far as the licensing authority has
knowledge, there have been no charges preferred nor has any information been presented relating to any question of unprofessional
or immoral conduct.
Signature __________________________________________________________________________ Date _______ / _______ / _______
mo.
day
yr.
Title _______________________________________________________________________
Agency _____________________________________________________________________
Address ____________________________________________________________________
(LICENSING AUTHORITY
____________________________________________________________________________
SEAL)
Telephone number ____________________________ Fax ___________________________
E-mail _____________________________________________________________________
New York State Education Department, Office of the Professions, Division of Professional
RETURN DIRECTLY TO:
Licensing Services, Podiatry Unit, 89 Washington Avenue, Albany, NY 12234-1000
Podiatrist Form 3, Page 2 of 2 (Rev. 08/04)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form 3 - Verification Of Chiropractic Licensure In Another Jurisdiction Form 3 - Verification Of Chiropractic Licensure In Another Jurisdiction Legal
Podiatrist Form 2 - Certification Of Professional Education - New York The State Education Department Podiatrist Form 2 - Certification Of Professional Education - New York The State Education Department Legal
Form 3a Verification Of Medical Licensure In Another Country Form 3a Verification Of Medical Licensure In Another Country Legal
Form 3 - Certification Of Out-of-state Licensure And Examination Grades - The State Education Department, The University Of The State Of New York Form 3 - Certification Of Out-of-state Licensure And Examination Grades - The State Education Department, The University Of The State Of New York Legal
Form 3 - Certificate Of Legal Practitioner And Waiver By Purchaser Form 3 - Certificate Of Legal Practitioner And Waiver By Purchaser Business
Form 3 - Certificate Of Completion Template Form 3 - Certificate Of Completion Template Business
Ophthalmic Dispensing Form 3 - Certification Of Ophthalmic Dispensing License In Another Jurisdiction - New York The State Education Department Ophthalmic Dispensing Form 3 - Certification Of Ophthalmic Dispensing License In Another Jurisdiction - New York The State Education Department Legal
Physical Therapy Form 3 - Certification Of Physical Therapist Or Physical Therapist Assistant Licensure In Another State Physical Therapy Form 3 - Certification Of Physical Therapist Or Physical Therapist Assistant Licensure In Another State Legal
Psychology Form 3 - Certification Of Out Of State Licensure And Examination Grades - New York State Education Department Psychology Form 3 - Certification Of Out Of State Licensure And Examination Grades - New York State Education Department Legal
Dental Hygiene Form 3 - Certification Of Licensure - The State Education Department Dental Hygiene Form 3 - Certification Of Licensure - The State Education Department Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2