Ophthalmic Dispensing Form 2 - Certification Of Professional Education In Ophthalmic Dispensing - New York State Education Department

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Ophthalmic Dispensing
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Form 2
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF PROFESSIONAL EDUCATION
IN OPHTHALMIC DISPENSING
APPLICANT INSTRUCTIONS
1. Complete Section I in ink. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 7.
2. Send this form to the institution(s) you attended for completion of Section II and the certification. Be sure to include any fee required by the
institution. A separate Form 2 should be submitted for each professional educational program you attended.
3. This form must be signed by the registrar of the institution and returned directly in a sealed school envelope to the Office of the Professions at
the address at the end of the form.
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
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
5
Print name under which degree was awarded: ___________________________________________________________________
6
Title of degree: ____________________________________________________________ Date degree was awarded: _______ / _______ / _______
mo.
day
yr.
Professional school attended: _________________________________________________________________________________________
I request and give my permission to the institution listed in item 6 above to complete the information on this form and send any documentation
7
requested, including that requested on this form (e.g. an official transcript), to the New York State Education Department.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Ophthalmic Dispensing Form 2, Page 1 of 2, Rev. 12/04

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