Form 2 - Certification Of Education printable pdf download

Form 2 - Certification Of Education

FORM 2

The University of the State of New York

THE STATE EDUCATION DEPARTMENT

Office of the Professions

CERTIFIED SHORTHAND

Division of Professional Licensing Services

REPORTING

89 Washington Avenue

Albany, NY 12234-1000

CERTIFICATION OF EDUCATION

APPLICANT INSTRUCTIONS

Complete Section I. Be sure to sign and date item 10.

Forward this form to your high school or secondary school and, if applicable, school where you completed your technical study in manual or machine

shorthand reporting. Request that the Registrar attach a certified transcript to this form and return it directly to the Office of the Professions at the

address at the bottom of this form. Be sure to include any fee required by the school. Photocopy this form, as necessary. This form will not be accepted

if submitted by the applicant.

SECTION I: APPLICANT INFORMATION

SOCIAL SECURITY NUMBER

BIRTH DATE

Month

Day

Year

(Leave this blank if you do not have a U.S. Social Security Number)

PRINT YOUR FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)

Last

First

Middle

MAILING ADDRESS:

(You must notify the Department promptly of any address or name changes.)

Street

City

Zip Code

State

Province/Country

If not U.S.

Check the appropriate box for transcript being requested:

High School or GED

Technical Study in Manual or Machine Shorthand Reporting

Name of school: __________________________________________________________________________________________________________

Print name under which degree was awarded or study completed: ___________________________________________________________________

Dates of Study: From: _______ / _______ / _______

To: _______ / _______ / _______

mo.

day

yr.

mo.

day

yr.

Was a degree awarded?

Yes

If yes, title: _____________________________________________________________

Date: _______ / _______ / _______

mo.

day

yr.

I request and give my permission to the school listed in item 6 above to send an official transcript to the New York State Education Department's Office

of the Professions.

__________________________________________________________________________

________________________________

Applicant's signature

Date

FORM 2

April 2003