Psychology Form 3 - Certification Of Out Of State Licensure And Examination Grades - New York State Education Department
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1
2The University of the State of New York
FORM 3
THE STATE EDUCATION DEPARTMENT
Office of the Professions
PSYCHOLOGIST
Division of Professional Licensing Services
CERTIFICATION OF OUT-OF-STATE LICENSURE
AND EXAMINATION GRADES
APPLICANT INSTRUCTIONS
1.
Complete Section I in ink. Be sure to enter your name exactly as it appears on your Licensure Application (Form 1) and sign and date the
appropriate authorization in item #8.
2.
Send this form to the licensing authority in the appropriate jurisdiction where you are or have been licensed. Ask the licensing authority to
complete Section II and return the form directly to the Office of the Professions. Be sure to include any fee required.
Examination grades
should be reported by the jurisdiction in which the examination was taken. Applicants who are licensed in another jurisdiction must have a
Form 3 submitted from each jurisdiction where a license was granted.
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 FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
Last
First
5
TELEPHONE/E-MAIL ADDRESS
Middle
Daytime Phone
4
MAILING ADDRESS
(You must notify the Department promptly of any address or name changes.)
Area Code
Phone Number
Line 1
E-Mail Address (Please print clearly)
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
If you entered a licensing examination in the United States using a different name, enter that name below:
Last ___________________________________________ First _____________________________________ Middle ______________________
7
If you were licensed by examination in the United States or Canada, give state, territory or province: _______________________________________
8
Enter the name of the licensing authority: ______________________________________________________________________________________
I request and give permission to the licensing authority named above to complete the information on this form and send any documentation requested
including that requested on this form to the New York State Education Department.
I am a licensed psychologist of your jurisdiction.
Signature: ____________________________________________________________________
Date: _______ / _______ / _______
mo.
day
yr.
License number: _________________________________ Date issued: _______ / _______ / _______
mo.
day
yr.
LICENSING AUTHORITY OF THE CERTIFYING STATE MUST COMPLETE THE NEXT PAGE
Rev. 9/15
FORM 3, PAGE 1 OF 2
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