Land Surveying Form 2 - Certification Of Professional Education - New York State Education Department
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1
2The University of the State of New York
Land Surveyor
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 2
Division of Professional Licensing Services
Certification of Professional Education
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 10.
2.
Send the entire form to the school where you completed your education and request that they complete the appropriate parts of Section
II and return this form directly to the Office of the Professions. Be sure to include any fee required by the school. Keep a copy for your
records.
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
Print name under which degree/diploma was awarded (if different from above):
Name: ______________________________________________________________________________________________________
6
6.
Secondary and/or preprofessional school attended: ___________________________________________________________________
(preceding professional school)
Dates of attendance from: ________ / ________ / ________
to: ________ / ________ / ________
mo.
day
yr.
mo.
day
yr.
7
7.
Professional school attended: ____________________________________________________________________________________
Dates of attendance from: ________ / ________ / ________
to: ________ / ________ / ________
mo.
day
yr.
mo.
day
yr.
8.
Was degree/certificate/diploma awarded?
Yes
No
8
If yes, Title: _______________________________________________ Field: ______________ Date ________ / ________ / ________
mo.
day
yr.
9.
Check all that apply:
Day student
Evening student
Part-Time student
Co-op student
9
Branch campus at _________________________________________________________________________
9.
I request and give my permission to the school listed in item 6 and/or 7 above to attach an official transcript to this form and to mail it
10
and any other information requested in connection with my application for licensure to the New York State Education Department at the
address at the end of this form.
Applicant’s Signature: _____________________________________________________________
________ / ________ / ________
mo.
day
yr.
Land Surveyor Form 2, Page 1 of 2 (Rev. 5/09)
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