Form 2 - Certification Of Professional Education Form printable pdf download

Form 2 - Certification Of Professional Education Form

Professional Engineering

The University of the State of New York

Form 2

THE STATE EDUCATION DEPARTMENT

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. Enter your name exactly as it appears on your application (Form 1). Be sure to sign and date item 9.

2. Send this form to the institution(s) which you attended and ask that they return it directly to the Office of the Professions. Be sure to include any fee

required by the school. A separate Certification of Professional Education must be submitted for each educational program you attended.

Note:

If you attended or graduated from a program that’s NOT ABET accredited and/or if you attended a graduate program, ask your school to attach an

official school transcript or marksheet to this form.

SECTION I: APPLICANT INFORMATION

Social Security Number

Birth Date

Month

Day

Year

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

Print Full Name

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

If different from above, print the name under which your degree was awarded:

______________________________________________________________________________________________________________________

Secondary and/or preprofessional school attended: _____________________________________________________________________________

(Name)

Professional school attended: _____________________________________________________________________________________________

(Name)

Month and year of graduation: ________________________________

Degree awarded: ______________________________________________

In: _____________________________________________________

(Title)

(Field)

If no degree, month and year of latest attendance: __________________________________________

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

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.

Professional Engineering Form 2, Page 1 of 2, June 2004

Form 2 - Certification Of Professional Education Form

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