Respiratory Therapy Form 2 - Certification Of Professional Education - New York The State Education Department
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1
2
3Respiratory Therapy
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Form 2
Office of the Professions
Division of Professional Licensing Services
Respiratory Therapist
89 Washington Avenue
Respiratory Therapy Technician
Albany, NY 12234-1000
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 9.
2. Send this form to the school(s) you attended and instruct them to complete the appropriate section of the form and attach an official transcript if
required. Be sure to include any fee required by the school. A separate Form 2 should be submitted for each educational program attended.
3. The institution which completes Section II must send this form directly to the Office of the Professions. It will not be accepted if submitted by the
applicant.
SECTION I: APPLICANT INFORMATION
Birth Date
1
2
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Full Name Exactly As It Appears On Your Licensure Application (Form 1)
Last
First
Middle
Mailing Address
You must notify the Department promptly of any address or name changes.
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print name under which certificate, degree or diploma was awarded:
___________________________________________________________________________________________________________
6
Secondary/Preprofessional school attended: ______________________________________________________________________________
7
Professional school attended: _________________________________________________________________________________________
Address: _________________________________________________________________________________________________________
8
Title of professional certificate, diploma or degree: ________________________________________________________________________
Date certificate, diploma or degree was awarded: _______ / _______ / _______
mo
day
yr.
9
I request and give my permission to the institution(s) listed in item 6 and 7 above to send any documentation requested, including that requested on
this form (e.g. an official transcript) to the New York State Education Department.
__________________________________________________________________________
________________________________
Applicant's signature
Date
Respiratory Therapy Form 2, Page 1 of 3, June 2004
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