Veterinary Medicine Form 2 - Certification Of Professional Education - New York The State Education Department
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1
2
3The University of the State of New York
FOR OFFICE USE ONLY
FORM 2
THE STATE EDUCATION DEPARTMENT
TENTATIVE
Office of the Professions
VETERINARIAN
Division of Professional Licensing Services
FINAL
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1.
Complete Section 1. Enter your name as it appears on your New York State Licensure Application (Form 1). Be sure to sign and date item 9.
2.
Send this form to the professional school you attended to complete Section II. Be sure to include any fee required by the school. Notify the school
that a transcript must accompany this form if the school is not registered by the Department or accredited by the AVMA. (See page 7 of this
application packet for additional information.)
3.
If you attended a veterinary school that has been closed, send this form to the official repository of the records for that school.
4.
This form must be signed by the registrar, dean, rector, or principal of the school and sent back directly to the Office of the Professions at the
address on the bottom of page 3 of this form by that individual or other designated school official in an official school envelope. Forms returned
by the applicant or other parties will not be accepted.
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 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
E-Mail Address (Please print clearly)
Daytime Phone
5
TELEPHONE/E-MAIL ADDRESS
Area Code
Phone Number
6
Print name under which your degree or diploma was awarded (
___________________________________________________
if different from above) :
7
Professional school attended: _____________________________________________________________________________________________
Address: ______________________________________________________________________________________________________________
8
Name of degree/diploma: ____________________________________________________ Date awarded: _______________________________
I request and give my permission to the school listed in item 7 above to complete the information on this form and send any documentation
9
requested by the NYS Education Department including that listed on pages 2 and 3 of this form (e.g., an official transcript) to the New York State
Education Department's Office of the Professions.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr
April 2004
FORM 2, PAGE 1 OF 3
CERTIFICATION BY PROFESSIONAL SCHOOL OFFICIAL IS TO BE MADE ON NEXT PAGES
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