Athletic Training Form 2b - Certification Of Equivalent Practicum Experience
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1
2The University of the State of New York
Athletic Trainer
THE STATE EDUCATION DEPARTMENT
Form 2B
Office of the Professions
Division of Professional Licensing Services
Certification of Equivalent Practicum Experience
[To be completed only by those applicants who did not complete a program registered by the New York Education Department (NYSED) as
licensure qualifying or accredited by the National Athletic Trainers’ Association (NATA) or by the Commission on Accreditation of Allied Health
Programs (CAAHP).]
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 your supervisor and request that they complete Section II and return both pages of the form in an envelope with their return
address directly to the Office of the Professions at the address at the end of the form. This form will not be accepted if returned by you.
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
5
Telephone/E-Mail Address
Middle
Daytime Phone
4
Mailing Address (You must notify the Department promptly of any address or name changes.)
Line 1
Area Code
Phone Number
Line 2
E-Mail Address (Please print clearly)
Line 3
City
State
Zip Code
Country/
Province
6
Experience described below was obtained at:
Organization Name: ________________________________________________________________________________________________________
Address: Street ____________________________________________________________________________________________________________
City ________________________________________________________ State ________________ Zip _________________________
Beginning _______ /_______ /_______ and ending _______ / _______ / _______
Total number of hours: _______________
mo.
day
yr.
mo.
day
yr.
Description of Experience: Describe in the space below your athletic training duties during your experience with the organization named above.
7
Identify the sports and specific professional activities that were part of this experience.
8
I hereby certify that the work experience described above and the time claimed for that experience are true and accurate.
Signature ___________________________________________________________________________________ Date: _______ / ______ / _______
mo.
day
yr.
Athletic Trainer Form 2B, Page 1 of 2, (Rev. 08/06)
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