Veterinary Technology Form 3 - Verification Of Out-Of-State Licensure, Registration, And/or Examination December 2004
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1
2The University of the State of New York
Veterinary Technician
THE STATE EDUCATION DEPARTMENT
Form 3
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
VERIFICATION OF OUT-OF-STATE LICENSURE, REGISTRATION
AND/OR EXAMINATION
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 7.
2.
Send this form with any fee required to the appropriate licensing authority of the state, province or country in which you are or have been licensed to
complete Section II and return this form directly to the Office of the Professions at the address at the end of this form. The Office of the Professions
will not accept this form if submitted by the applicant.
Note: A separate Form 3 must be received by the Department from every state, province and country in which you are or have been licensed.
SECTION I: APPLICANT INFORMATION
1
2
Social Security Number
Birth Date
Month
Day
Year
(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
If you took a licensing examination in the United States or were licensed in another jurisdiction using a different name, enter that name
below:
___________________________________________________________________________________________________________
(last)
(first)
(middle)
6
If licensed by examination in the United States, give state or territory: ____________________________________________________
Date license was issued: _____________________________________ License number: ___________________________________
7
I request and give my permission to the licensing authority to complete the information on this form and send any documentation
requested, including that requested on this form, to the New York State Education Department.
Applicant's signature:
Date:
/
/
____________________________________________________________________
_______
_______
_______
mo.
day
yr.
Veterinary Technician Form 3, Page 1 of 2, Rev. 12/04
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