Registered Physician Assistant Form 3 - Verification Of Licensure/certification In Another Jurisdiction - New York State Education Department Page 2

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Section II: Verification Of Licensure: (Please print or type)
INSTRUCTIONS TO THE LICENSING AUTHORITY: Please complete items 1-4, sign and date the certification and return this form directly
to the Office of the Professions at the address below. This form will not be accepted if returned by the applicant.
1
Name of applicant: ___________________________________________________________________________________________________
(see item 6 in Section I)
Professional title on license/certificate: ____________________________________________________________________________________
2
License/certificate number: _______________________________________________ Date of licensure/certification: ______ / ______ / ______
mo.
day
yr.
3
Verification of licensure
What requirements did the applicant meet to become licensed/certified in your jurisdiction?
Education:
__________________________________________________________________________________________________
Examination:
Examination title: ____________________________________________________________________________________
Date: ______ / ______ / ______ Score: _______________
Other:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
4
A.
Has the applicant identified in Section I been subject to any disciplinary action?
YES
NO
YES
NO
B.
Are any charges pending against this individual?
If the answer to either of these questions is "yes," please attach a complete explanation with any supporting documentation.
Certification
I hereby 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, except as noted in item 4 above or in any attachments, 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 nor has any information been presented relating to any question of unprofessional
or immoral conduct.
Signature: _____________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print name: ____________________________________________________________________
Title: _________________________________________________________________________
Licensing authority: _____________________________________________________________
(SEAL)
Address: _____________________________________________________________________
City: ________________________________________________ State __________________
Telephone: _______________________________ Fax: ________________________________
E-mail Address: _______________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Physician Assistant Unit,
89 Washington Avenue, Albany, NY 12234-1000.
Registered Physician Assistant Form 3, Page 2 of 2, May 2005

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