Form 4a - Identification Of Supervisor And Setting
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1
2Form 4A
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Speech-Language Pathologist
Division of Professional Licensing Services
Audiologist
Identification of Supervisor and Setting
Applicant Instructions
An Application for Licensure (Form 1) and Certification of Professional Education (Form 2) must be received and approved before
this form can be reviewed.
1.
Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1).
2.
Have your supervisor complete Section II, Part A.
3.
Complete the rest of Section II with your employer and/or supervisor and send the entire form directly to the Office of the Professions at
the address at the end of this form.
Section I: Applicant Information
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
3.
Print Name As It Appears On Your Application for Licensure (Form 1)
5
6.
Telephone/E-Mail Address
Last
Daytime phone
First
Area Code
Phone
Middle
E-mail Address
(please print clearly)
.
4
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
Section II: Identification of Supervisor and Setting
Part A - Identification of the Supervisor
Name: _________________________________________________________ Title: ________________________________________
Business Address: _____________________________________________________________________________________________
_______
______________________________________________________________________________________________________________
Telephone: ___________________ ext. _________ Fax number: _______________________ E-mail: __________________________
Are you employed at the same place of employment as the applicant?
Yes
No
If yes, how many hours per week are you employed there? ___________________
Credentials
Supervision must be provided by a New York State licensed Speech-Language Pathologist or Audiologist except experience gained
outside New York State or in an exempt setting may be provided by a person with the ASHA Certificate of Clinical Competence.
New York State license number: _________________________________________
ASHA number (if applicable): ___________________________________________
Speech-Language Pathology & Audiology Form 4A, Page 1 of 2, Rev. 1/11
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