Registered Physician Assistant Form 2 - Certification Of Professional Education
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1
2The University of the State of New York
Registered Physician
THE STATE EDUCATION DEPARTMENT
Assistant Form 2
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1.
Complete Section I in ink. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 8.
2.
Send this form to the institution(s) you attended for completion of Section Il and the certification. Be sure to include any fee required by the institution.
A separate Certification of Professional Education should be submitted for each professional educational program you attended.
3.
This form must be signed by the registrar of the institution and both pages of this form must be returned directly in a sealed school envelope to the
Office of the Professions at the address at the end of this form. Forms returned by the applicant will not be accepted.
Section I: Applicant Information
Social Security
Birth
1
2
Date
Number
mo .
day
yr.
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Your Name Exactly As It Appears On Your Licensure Application (Form 1)
Last
First
Middle
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
Print name under which certificate or degree was awarded: ___________________________________________________________
6
Professional school attended: __________________________________________________________________________________
7
Title of certificate or degree: ______________________________________________ Date awarded: _______ / _______ / _______
mo.
day
yr.
I request and give my permission to the institution listed in item 6 above to complete the information on this form and send any documentation
8
requested, including that requested on this form (e.g. an official transcript), to the New York State Education Department.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Registered Physician Assistant Form 2, Page 1 of 2, Rev. 05/05
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