Athletic Trainer Form 1 - Application For Certification

Athletic Trainer Form 1 - Application For Certification - 2016 Page 4

EDUCATION REVIEW

I give permission to the New York State Education Department to release my examination results to my professional school

for the confidential purposes of program review and institution research and planning. I may rescind this authority at any

time by notifying the Division of Professional Licensing Services in writing.

Yes

Please initial: _____________

AFFIDAVIT WITH ACKNOWLEDGMENT

(Notarization required.)

APPLICANT

I 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. This form must be signed and dated in the

presence of a Notary Public.

Signature of the applicant: _______________________________________________

Date __________ / __________ / __________

Month

Day

Year

NOTARY

State of __________________________________________ County of _______________________________________

On the ____________ day of ______________________ in the year __________ before me, the above signed,

personally appeared __________________________, personally known to me or proved to me on the basis of

Applicant Name

satisfactory evidence to be the individual whose name is subscribed to this application and acknowledged to me that

he/she executed the application and swore that the statements made by him/her in the application and all supporting

materials are true, complete, and correct.

Notary Public signature _____________________________________________________________________________

Notary ID number _______________________________

Notary Stamp

Expiration date __________ / __________ / __________

Month

Day

Year

Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,

NY 12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.

Athletic Trainer Form 1, Page 4 of 4, Rev. 6/16

Athletic Trainer Form 1 - Application For Certification - 2016 Page 4