Nurse Form 3 - Verification Of Other Professional Licensure/certification printable pdf download

The University of the State of New York

Nurse Form 3 (Check one)

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Registered Professional Nurse

Division of Professional Licensing Services

Licensed Practical Nurse

VERIFICATION OF OTHER PROFESSIONAL LICENSURE/CERTIFICATION

(Complete this form if you hold, or have ever held, a license or certificate to practice any profession* in any jurisdiction)

*Profession is defined as professional titles licensed under New York State Education Law (see page 2 of the Address/Name Change Form).

APPLICANT INSTRUCTIONS

1. Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 9.

2. Send the entire form to the appropriate licensing/certifying authority for completion of Section II. Be sure to include any fee required by that

licensing/certifying authority. We must receive a Form 3 for all professional licenses/certificates you ever held except those issued by the New York

State Education Department. This form will not be accepted if submitted by you.

Section I: Applicant Information

Social Security Number

Birth Date

Month

Day

Year

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

Print Your Name Exactly As It Appears On Your Application for Licensure (Form 1)

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

Licensing/certifying authority to which this form is being sent:

Print name of licensing/certifying authority ____________________________________________________________________________________

If you were issued a license/certificate by this licensing/certifying authority, print your name as it appears on your license/certificate.

Print name ____________________________________________________________________________________________________________

Professional title on license/certificate issued: _________________________________________________________________________________

If you took a licensing examination in the United States using a different name, enter that name below:

_______________________________________________ _______________________________________ ____________________________

Last

First

Middle

If licensed/certified as a nurse, name of school of nursing: _______________________________________________________________________

Address: ______________________________________________________________________________________________________________

Date certificate or diploma in nursing was awarded or is expected to be awarded: _______ / _______ / _______

mo.

day

yr.

I request and give my permission to the licensing/certifying authority listed in item 5 above to complete the information on this form and mail it to the

New York State Education Department and to release any other information required by the State Education Department in connection with my

application for licensure. I also 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.

Applicant's signature: ______________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Nurse Form 3, Page 1 of 2, Rev. 1/13

Nurse Form 3 - Verification Of Other Professional Licensure/certification

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