Athletic Trainer Form 1 - Application For Certification

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Do you now hold, or have you ever held, a license or certificate to practice any profession* in any jurisdiction?

Yes

If yes, list each license/certificate, state or jurisdiction and provide appropriate information in the columns below. A Form 3 must be submitted for

each professional license/certificate listed unless it is a license/certificate issued by the New York State Education Department. See the

Applicant Instructions on Form 3 for specific information about completing and submitting the form.

*Profession is defined as professional titles licensed under New York State Education Law.

Limitations

Date License/Certificate

License/Certificate

Professional Title

State or Jurisdiction

Issued

Number

On License/Certificate

GENDER AND ETHNICITY: (This item is optional.)

Information on gender and ethnicity is sought solely to allow the New York State Education Department to collect and analyze data concerning

diversity in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and program evaluation

purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for licensure.

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GENDER:

Male

Female

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ETHNICITY:

White (not Hispanic)

Black (not Hispanic)

Asian

Hispanic

Native American

CHILD SUPPORT OBLIGATION:

Everyone applying for a professional license, permit, or registration, or any renewal thereof, must file a written statement that, as of the date of the filing,

she or he is, or is not, under an obligation to pay child support*. Individuals who are four months or more in arrears in child support or who have

failed to comply with a summons, subpoena or warrant relating to a paternity or child support proceeding may be subject to suspension of their

business, professional, drivers and/or recreational licenses and permits. The intentional submission of false written statements for the purpose of

frustrating or defeating the lawful enforcement of support obligations is punishable under section 175.35 of the Penal Law.

You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance with their obligation

to pay child support can be issued a credential for no more than six months in order to comply with their child support obligations.

CHECK ONLY A OR B BELOW. If you check B, you must check one of the five statements listed below it.

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I am not under an obligation to pay child support:

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I am under an obligation to pay child support and (please check only one of the following)

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I am current and am not four months or more in arrears in the payment of child support: or,

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I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or,

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