Veterinary Medicine Form 2ppe - Certification Of Pre-Professional Education - New York The State Education Department

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The University of the State of New York
FORM 2PPE
THE STATE EDUCATION DEPARTMENT
Office of the Professions
VETERINARIAN
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF PRE-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 10.
2.
Send this form with a request for an official transcript to the college you attended before entering your veterinary medical school. Be sure to
include any fee required. Notify the college that this form must accompany your official transcript.
3.
If you attended a college that has been closed, send this form to the official repository of the records for that college.
4.
This form must be signed by the registrar, dean, rector, or principal of the college and sent back along with your transcript directly to the Office of
the Professions at the address at the bottom of page 2 of this form by that school official in an official school envelope. Forms sent back 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
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
E-Mail Address (Please print clearly)
Daytime Phone
5
TELEPHONE:
Area Code
Phone Number
6
Pre-professional college attended: __________________________________________________________________________________________
7
Print name under which you were enrolled at this college (
_______________________________________________________
if different from above).:
8
Dates of attendance: ___________________________________________ To: ______________________________________________________
9
Name of degree/diploma issued: ________________________________________________ Date awarded: _______________________________
I request and give my permission to the school listed in item 6 above to attach to this form an official transcript and mail it to the New York State
10
Education Department's Office of the Professions and to release any other information required by the Office of the Professions in connection with
my application for licensure.
Applicant's Signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
April 2004
FORM 2PPE, Page 1 of 2

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