Athletic Trainer Form 1 - Application For Certification - 2016
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4The University of the State of New York
Department Use Only
Athletic Trainer
THE STATE EDUCATION DEPARTMENT
Form 1
Office of the Professions
Division of Professional Licensing Services
Application for Licensure
Applicants Must Complete All Four Pages Of This Application In Ink
All applicants for licensure must complete this form and submit it with the $158 licensure and
registration fee directly to the Office of the Professions at the address at the end of this form. You must
answer all questions and provide all information requested unless otherwise indicated. Failure to
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$158
ER
1
complete all required parts of the application will delay its review. You must sign and date the Affidavit on
this form in the presence of a Notary Public.
NYS License Number
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Date Issued
3
Birth Date
Month
Day
Year
Initials
4
Print Name
Last
6
Telephone/E-Mail Address
First
Daytime Phone: Home or Business
Middle
Area Code
Phone Number
Licensee business address, phone and e-mail address are public information. Failure to indicate
business or home on this form for each item will deem it public information.
E-Mail Address (Please print clearly)
Home or Business
5
Mailing Address: Home or Business
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
7
New York State DMV ID Number
(Driver or Non-Driver)
City
State
Zip Code
Country/
(Leave this blank if you do not have a
New York State DMV ID Number)
Province
8
Name as it appears on degree or other credentials (if different from above): ___________________________________________________________
9
Have you ever applied for licensure or certification in New York State?
Yes
No
If yes, which profession? _____________________________________________________________________________
10
CITIZENSHIP/IMMIGRATION STATUS:
Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses, registrations
and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation, you must complete
this section of this form and check the appropriate box below which indicates your citizenship/immigration status.
I am:
A.
A United States citizen or National.
B.
An alien lawfully admitted for permanent residence in the United States.
C.
An alien granted asylum under Section 208 of the Immigration and Nationality Act.
D.
A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
E.
An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.
F.
An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
G.
An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.
H.
Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not required to
have a Visa to enter the United States: _______________________________________
I.
I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar
relief from deportation. Please specify: _______________________________________
J.
I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship and
Immigration Services (USCIS):
USCIS number: ___________________________________________
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL LAW SHOULD
BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283, OR VISIT THEIR WEB SITE
AT
Athletic Trainer Form 1, Page 1 of 4, Rev. 6/16
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