Clinical Nurse Specialist Form 3 - Verification Of Other Professional Licensure/certification - 2014
ADVERTISEMENT
1
2The University of the State of New York
Clinical Nurse Specialist
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 3
Division of Professional Licensing Services
Verification of Other Professional Licensure/Certification
(Complete this form if you hold a license or certificate to practice as a clinical nurse specialist
in any other state or another country)
Applicant Instructions
1.
Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and
date item 7.
2.
Send this entire form to the appropriate licensing/certifying authority for completion of Section II. Be sure to include any fee required by
the government licensing/certifying authority. We must receive a Form 3 for all licenses/certificates you ever held except those issued by
the New York State Education Department. This form will not be accepted if submitted by the applicant.
Section I: Applicant Information
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
3.
Print Name as It Appears on Your Application for Licensure (Form 1)
Last
First
Middle
4
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
5.
Licensing/certifying authority to which this form is being sent:
Print name of licensing/certifying authority __________________________________________________________________________
6
6.
Print your name as it appears on your license/certificate from the licensing/certifying authority listed in item 5.
Print name ___________________________________________________________________________________________________
Professional title on license/certificate issued _______________________________________________________________________
7
8.
I request and give my permission to the licensing/certifying authority listed in item 5 above to complete the information on this form and
mail it to the New York State Education Department and to release any other information required by the State Education Department in
connection with my application for licensure. I also declare and affirm that the statements made in this application, including
accompanying documents, are true, complete and correct. I understand that any false or misleading information in, or in connection
with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.
_________________________________________________________________________________ __________________________
Applicant’s Signature
Date
Clinical Nurse Specialist Form 3, Page 1 of 2, July 2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Mental Health Counselor Form 3 - Verification Of Other Professional Licensure/certification - 2010
Legal
Marriage And Family Therapist Form 3 - Verification Of Other Professional Licensure/certification - 2010
Legal
Creative Arts Therapist Form 3 - Verification Of Other Professional Licensure/certification - 2010
Legal
Related Categories
Parent category: Legal