Medicine Education Record Form - Medicine Education Record - New York State Education Department Page 2

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7.
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Please print clearly giving an accurate record of your educational preparation below. You must complete all information for all
schools/colleges/universities attended and diplomas and/or degrees received or your application will be considered
incomplete. Attach additional sheets if necessary.
Name of High School/Secondary School or GED Diploma issuer: _____________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Number of years attended: ____________________ Attendance from: _______ / _______ / _______ to _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Graduation date: _______ / _______ / _______ or Date GED issued: _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Postsecondary/Preprofessional Education (Exclusive of Medical School)
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ / _______ to _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______ / _______
mo.
day
yr.
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ / _______ to _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______ / _______
mo.
day
yr.
Medical Education (Professional, list all medical schools attended)
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ / _______ to _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______ / _______
mo.
day
yr.
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ / _______ to _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______ / _______
mo.
day
yr.
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Medicine Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Medicine Education Record Form, Page 2 of 2, Rev. 1/16

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