Form 2 - Certification Of Education

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FORM 2
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
CHIROPRACTIC
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF EDUCATION
APPLICANT INSTRUCTIONS
If you attended a New York State licensure qualifying chiropractic program, you do not need to submit this form. The program will submit your
information to New York.
1. Complete Section 1. Enter your name as it appears on your Application (Form 1). Be sure to sign and date item 8.
2. Send this form to the institution you attended. Be sure to include any fee required by the school. The institution which completes Section II must
return this form directly in an official school envelope to the Office of the Professions at the address at the end of this form.
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 YOUR FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
Last
First
Middle
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
5
Print name under which degree or diploma was awarded (if different from item 3):
__________________________________________________________________
6
Preprofessional School attended: __________________________________________
Date degree was awarded: _______ / _______ / _______
Mo.
Day
Yr.
Address: ______________________________________________________________________________________________________________
7
Professional school attended: _____________________________________________
Date degree was awarded: _______ / _______ / _______
Mo.
Day
Yr.
Address: ______________________________________________________________________________________________________________
I request and give my permission to the school(s) listed in item 7 above to complete Section II of this form and mail it to the New York State
8
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.
February 2004
FORM 2, PAGE 1 OF 2
CERTIFICATION BY PROFESSIONAL SCHOOL OFFICIAL IS TO BE MADE ON NEXT PAGE

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