Psychology Form 3 - Certification Of Out Of State Licensure And Examination Grades - New York State Education Department Page 2
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2SECTION II: CERTIFICATION OF LICENSURE
INSTRUCTIONS TO THE LICENSING AUTHORITY: Please complete this section and sign and date the certifying statement. This form must be
returned directly to the Office of the Professions at the address at the end of the form. This form will not be accepted if returned by the applicant.
1.
Exact title under which the applicant was licensed or certified as a psychologist: ____________________________________________________
2.
License Number: _____________________________ Date issued: ______ / _______ / _______
mo.
day
yr.
Yes
No
3.
Is the applicant currently licensed or registered to practice?
Yes
No
4.
Was the license granted at the independent practice level and based upon having received a doctoral degree in psychology?
5.
Was the license based on the ASPPB examination entitled Examination for Professional Practice in Psychology administered
Yes
No
in 1977 or thereafter on national testing dates for the written form or by computerized examination?
If yes,
Date on which the exam was administered ______ / _______ / _______
mo.
day
yr.
Scaled score achieved by applicant: _______________
Form number of the exam: ______________________
6.
If the psychologist was licensed or certified without examination, please explain on what basis the license or certificate was granted:
(attach additional sheets if necessary)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
7.
If the exam was "waived", please provide dates of waiver period in your state or province: _________________________________________
8.
If licensure or certification involved any special condition, please explain ______________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Yes
9.
Was there ever any disciplinary action against this license?
No
If so, please explain (attach additional sheets if necessary)_________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Yes
No
10. Are there any disciplinary charges pending against this license?
If so, please explain (attach additional sheets if necessary _________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
CERTIFICATION
I certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named on this form. I further certify that,
other than those listed above, this licensing authority has never taken any disciplinary action against this person and that, in so far as the licensing
authority has knowledge, there have been no charges preferred or sustained except as noted in questions 9 and 10 above.
Signature: ___________________________________________________________________
Date: _______ / _______ / _______
mo.
day
yr.
Print name: __________________________________________________________________
Name of licensing authority: ____________________________________________________
(SEAL OF LICENSING
Title or official position: ________________________________________________________
AUTHORITY)
Telephone: _______________________________ Fax: _______________________________
E-mail: ______________________________________________________________________
RETURN DIRECTLY
New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Psychology
TO:
Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Rev. 9/15
FORM 3, PAGE 2 OF 2
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