Form 2 - Certification Of Education Page 2
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1
2SECTION II : CERTIFICATION OF EDUCATION
INSTRUCTIONS TO SCHOOL REGISTRAR: Please complete either A or B below, and complete the certification. Sign the certification and
return this form with a transcript if required directly to the New York State Education Department, Division of Professional Licensing Services. It
will not be accepted if incomplete or if returned by the applicant.
Professional Education (Attach transcript)
A.
Programs Accredited by CCE or New York licensure qualifying programs.
(The chiropractic program has been completed and the degree awarded).
______________________________________________________________ was admitted on _______________________ and
was
Applicant name (Item 3, Section I)
mo.
day
yr.
awarded ______________________________________________________________________________ on ____________________ .
Title of degree
mo.
day
yr.
B.
All others – Submit a transcript with this form
(The chiropractic program has been completed and the degree awarded).
______________________________________________________________ was admitted on _______________________ and satisfactorily
Applicant name (Item 3, Section I)
mo.
day
yr.
completed the program on ____________________ and was awarded _________________________________ on ____________________ .
mo.
day
yr.
Title of degree
mo.
day
yr.
CERTIFICATION
I hereby certify that to the best of my knowledge and belief the foregoing information in Section II is a true statement of the professional educational
record of the individual named on this form.
Signature: ___________________________________________________________________ Date: _____ / _____ / _____
mo.
day
yr.
Type or print name: ___________________________________________________________
Title or official position: ________________________________________________________
Institution: ___________________________________________________________________
(COLLEGE
SEAL)
Location: ____________________________________________________________________
Telephone number: ____________________________________________________________
Fax: ________________________________________________________________________
E-mail: ______________________________________________________________________
RETURN DIRECTLY
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
TO:
Chiropractic Unit, 89 Washington Avenue, Albany, NY 12234-1000.
February 2004
FORM 2, PAGE 2 OF 2
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