Registered Physician Assistant Form 3 - Verification Of Licensure/certification In Another Jurisdiction - New York State Education Department

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The University of the State of New York
Registered Physician
THE STATE EDUCATION DEPARTMENT
Assistant Form 3
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
VERIFICATION OF LICENSURE/CERTIFICATION IN ANOTHER JURISDICTION
(Complete this form if you are or have been licensed/certified in another jurisdiction)
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 7.
Send this form to the appropriate state(s), province(s), or country(ies). We must receive a form from the licensing authority of
2.
every jurisdiction in which you are or have ever been licensed/certified. Be sure to include any fee required by that licensing
authority.
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 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
Jurisdiction to which this form is being sent:
Print name of licensing authority ___________________________________________________________________________
6
Print your name as it appears on your license/certificate from jurisdiction listed in item 5.
Print name ____________________________________________________________________________________________
Professional title on license/certificate _______________________________________________________________________
7
I request and give my permission to the licensing 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.
Applicant's signature: __________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Registered Physician Assistant Form 3, Page 1 of 2, May 2005

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