Podiatry Form 4pgy - Certification Of Approved Podiatric Postgraduate Training - New York The State Education Department
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1
2The University of the State of New York
Podiatrist Form 4PGY
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF APPROVED PODIATRIC POSTGRADUATE TRAINING
(To be used only for U.S. approved postgraduate podiatry training programs)
APPLICANT INSTRUCTIONS
1.
Complete Section I. 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 the Director of Podiatric Medical Education of the hospital(s) in which you completed postgraduate training and ask that they
complete Section II. Submit one form for each residency. You may photocopy this form as needed.
3.
The hospital must send this form directly to the New York State Education Department. If the hospital in which you did your residency does not
have a Director of Podiatric Medical Education, the form may be completed by the department chair. If the Education Department cannot determine
that this verification came directly from the hospital, you will not receive credit for the postgraduate hospital training.
SECTION I: APPLICANT INFORMATION
BIRTH DATE
SOCIAL SECURITY NUMBER
1
2
yr.
mo.
day.
(Leave this blank if you do not have a U. S. Social Security Number)
PRINT YOUR FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
3
Last
First
Middle
MAILING ADDRESS (
4
You must notify the Department promptly of any name or address changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
Daytime Phone
E-Mail Address (Please print clearly)
5
TELEPHONE/E-MAIL ADDRESS
Area Code
Phone Number
6
Print name under which postgraduate training
was completed (if different from above): ___________________________________________________________________________________
7
Hospital in which postgraduate training was completed: ____________________________________________________________
Address: _________________________________________________________________________________________________
I request and give my permission to the hospital listed in item 7 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 4PGY, Page 1 of 2 (Rev. 08/04)
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