Medicine Education Record Form - Medicine Education Record - New York State Education Department

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The University of the State of New York
Medicine Education
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Record Form
Division of Professional Licensing Services
Medicine Education Record
Instructions: Please complete this form and return it to the Office of the Professions at the address at the end of the form. Your signature
must be notarized by a Notary Public.
1
1.
Social Security Number
2
2.
Birth Date
Month
Day
Year
3.
3
Print Name
Last
First
Middle
4
4.
Mailing Address
(you must notify the Department promptly of any address or name changes using the
Address/Name Change Form which can be found on our Web site at /anchange.pdf.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
6.
Affidavit With Acknowledgment (Notarization required.)
Applicant
I 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. This form must be signed and dated in the presence of a Notary Public.
Signature of the applicant: ______________________________________________________________________________________
Date __________ / __________ / __________
Month
Day
Year
Notary
State of __________________________________________________ County of __________________________________________
On the ____________ day of ______________________ in the year __________ before me, the above signed, personally appeared
_____________________________________________, personally known to me or proved to me on the basis of satisfactory evidence
Applicant Name
to be the individual whose name is subscribed to this application and acknowledged to me that he/she executed the application and
swore that the statements made by him/her in the application and all supporting materials are true, complete, and correct.
Notary Public signature _________________________________________________________________________________________
Notary ID number _______________________________
Notary Stamp
Expiration date __________ / __________ / __________
Month
Day
Year
Medicine Education Record Form, Page 1 of 2, Rev. 1/16

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