Athletic Training Form 2 - Certification Of Professional Education

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The University of the State of New York
Athletic Trainer
THE STATE EDUCATION DEPARTMENT
Form 2
Office of the Professions
Division of Professional Licensing Services
Certification of Professional Education
APPLICANT INSTRUCTIONS
1.
Complete Section I. In item 3, enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 8.
2.
Send the entire form to the institution you attended and ask the Registrar to complete the appropriate parts of Section II and forward both pages of the
form in an official school envelope directly to the Office of the Professions at the address at the end of the form. Be sure to include any fee required by
the institution. This form will not be accepted if submitted by you. Photocopy this form as needed.
Section I: Applicant Information
1
2
Social Security Number
Birth Date
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Name 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.)
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print exact name under which your degree was awarded:
6
Secondary institution attended:
7
Professional school attended:
Address:
Date degree was awarded:
/
/
mo.
day
yr.
Name of degree issued:
Dates of attendance from
/
/
to:
/
/
mo.
day
yr.
mo.
day
yr.
8
I request and give my permission to the school listed in item 7 above to complete Section II of this form and mail it to the New York State Education
Department at the address at the end of this form, and to release any other information requested by the State Education Department in connection
with my application for licensure.
Applicant's signature:
Date:
/
/
mo.
day
yr.
Athletic Trainer Form 2, Page 1 of 2, (Rev. 08/06)

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