Education Record Form printable pdf download

Education Record Form

The University of the State of New York

The State Education Department

Education Record Form

Office of the Professions

Division of Professional Licensing Services

Instructions: Please complete this form, have it notarized by a Notary Public and return it to the Office of the Professions at the address at

the end of this form.

Social Security Number

(Leave this blank if you do not have a U.S. Social Security Number)

Birth Date

Month

Day

Year

Print Your Name Exactly As You Wish it to Appear On Your License

Last

First

Middle

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

Profession:

Affidavit with Acknowledgement (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.

Applicant's Signature

Date

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

Applicant name

of satisfactory evidence 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's Signature

Notary Stamp

Notary ID number

Expiration Date

Education Record Form, Page 1 of 2, Rev. 12/17

Education Record Form

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