Interior Design Form 2 - Certification Of Professional Education - The State Education Department
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1
2The University of the State of New York
Interior Design
THE STATE EDUCATION DEPARTMENT
Form 2
Office of the Professions
Division of Professional Licensing Services
Certification of Professional Education
Applicant Instructions
1.
Complete Section I in ink. Enter your name as it appears on your licensure application (Form 1). Be sure to sign and date item 8.
2.
Have the professional school you attended complete the appropriate parts of Section II. Be sure to include any fee required by the
school. The registrar must return this form in a sealed school envelope directly to the Office of the Professions at the address at the
bottom of page 2 of this form. This form will not be accepted if submitted by the applicant.
Section I: Applicant Information
1
1.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2
2.
Birth Date
Month
Day
Year
3
3.
Print Name
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
Print name under which degree or diploma was awarded: ______________________________________________________________
6
Secondary institution attended: ___________________________________________________________________________________
7
Professional school attended: ____________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Date diploma was awarded: ______ / ______ / ______
mo.
day
yr.
Name of degree/diploma issued: __________________________________________________________________________________
Dates of attendance from ______ / ______ / ______ to: ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
8
I request and give my permission to the school listed in item 7 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: _____________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Interior Design Form 2, Page 1 of 2, Rev. 12/13
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