Veterinary Technology Form 2 - Certification Of Professional Education December 2004 Page 2
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2SECTION II : CERTIFICATION OF PROFESSIONAL EDUCATION
INSTRUCTIONS TO REGISTRAR:
1.
If the applicant completed a New York State licensure qualifying program or a program accredited by the
American Veterinary Medical Association Committee on Veterinary Technician Education and Activities
(CVTEA), you must complete Part A and Part C.
2.
All other programs – You must complete Part B and Part C.
Please return this form directly to the Office of the Professions at the address at the end of this form. DO NOT
RETURN THIS FORM TO THE APPLICANT.
Applicant name: _____________________________________________________________________________________________________________
(See Section I, item 6)
PART A – PROGRAMS REGISTERED AS LICENSURE QUALIFYING BY THE NEW YORK STATE EDUCATION DEPARTMENT OR ACCREDITED BY
THE CVTEA. To be completed only by those institutions where the applicant completed a veterinary technology program registered by the New York State
Education Department as qualifying for licensure or accredited by CVTEA.
1. Applicant’s entrance date: _______ / _______ / _______
Completion/withdrawal date: _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
2. Degree/diploma conferred: ____________________________________________________________ Date of conferral: _______ / _______ / _______
(Include major; eg., AAS in Veterinary Technology)
mo.
day
yr.
The curriculum completed at the time the degree was awarded was:
! registered by the New York State Education Department as licensure qualifying; or
! accredited by the CVTEA.
PART B – ALL OTHER PROGRAMS To be completed only by those institutions not registered by the New York State Education Department as qualifying
for licensure or not accredited by CVTA.
1. Applicant’s entrance date: _______ / _______ / _______
Completion/withdrawal date: _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
2. Degree/diploma conferred: ____________________________________________________________ Date of conferral: _______ / _______ / _______
mo.
day
yr.
How many years of education and what credential is required for admission into your program? ______________________________________________
___________________________________________________________________________________________________________________________
What pre-professional credential/degree was submitted by the applicant for admission into your school? _______________________________________
___________________________________________________________________________________________________________________________
Submit with this form:
A.
An official transcript (course record, index, or marksheets) showing courses taken at your institution
(and any courses accepted from other institutions for transfer of credit or convalidation, if appropriate).
The transcript must bear the original signature of the registrar or designated official and original seal of the school.
B.
A copy of documentation from your files to support the granting of transfer credit or convalidated courses.
PART C – CERTIFICATION (Note: Certification is not acceptable unless dated and submitted after the applicant’s graduation.)
I certify that the information shown above is true and correct, according to the records of this institution.
Signature of Registrar: _________________________________________________________ Date: ______ / ______ / ______
mo.
day
yr.
Type or print name: ___________________________________________________________
Title: _______________________________________________________________________
(INSTITUTION
Institution: ___________________________________________________________________
SEAL)
Address: ____________________________________________________________________
____________________________________________________________________
Telephone: _______________________________ Fax: _______________________________
E-mail address: _______________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Veterinary Technology
Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Veterinary Technician Form 2, Page 2 of 2, Rev. 12/04
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