Veterinary Medicine Form 2ct - Certification Of Clinical Training - New York The State Education Department

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The University of the State of New York
FORM 2CT
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
VETERINARIAN
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF CLINICAL TRAINING
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 6.
2.
If you completed clinical training in a country other than where your veterinary school is located, send this form to the veterinary hospital/clinic or school
in which you completed your training.
3.
One form must be submitted to verify each experience. You may make additional copies of this form if needed.
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 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
5
Name of veterinary hospital/clinic where applicant received training:
__________________________________________________________________________________________________________
Dates worked: __________ / __________ / __________
to
__________ / __________ / __________
mo.
day
yr.
mo.
day
yr.
6
I request and give my permission to the veterinary clinic listed above to complete the information on this form and send any
documentation requested, including that listed on page 2 of this form, to the Office of the Professions of the New York State Education
Department.
Applicant's Signature: ____________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
April 2004
Form 2CT, Page 1 of 2

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