Veterinary Technology Form 2 - Certification Of Professional Education December 2004

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The University of the State of New York
Veterinary Technician
THE STATE EDUCATION DEPARTMENT
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 1 in ink. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 9.
2.
Send this form to the professional school you attended to complete Section II and attach an official transcript if required. Be sure to include any
fee required. If you attended a school that has been closed, send this form to the official repository of the records for that school.
3.
This form must be signed by the registrar or designated official of the school and sent back directly to the Office of the Professions by that
individual or other designated school official in an official school envelope. Forms returned by the applicant will not be accepted.
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 Full 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
E-Mail Address (Please print clearly)
Daytime Phone
5
Telephone/E-Mail
Area Code
Phone Number
6
Print name under which your degree or diploma was awarded (
___________________________________________________
if different from above) :
7
Institution attended: ______________________________________________________________________________________________________
Address: ______________________________________________________________________________________________________________
8
Name of degree/diploma: ____________________________________________________ Date awarded: _______________________________
I request and give my permission to the institution listed in item 7 above to complete the information on this form and send any documentation
9
requested, including that requested on this form (e.g. an official transcript), to the NYS Education Department.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Veterinary Technician Form 2, Page 1 of 2, Rev. 12/04

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