Form 3 - Verification Of Chiropractic Licensure In Another Jurisdiction printable pdf download

Form 3 - Verification Of Chiropractic Licensure In Another Jurisdiction

ALL

APPLICANTS

MUST

FORM 3

The University of the State of New York

COMPLETE THIS FORM IF

THE STATE EDUCATION DEPARTMENT

LICENSED ELSEWHERE

Office of the Professions

CHIROPRACTIC

Division of Professional Licensing Services

89 Washington Avenue

Albany, NY 12234-1000

VERIFICATION OF CHIROPRACTIC LICENSURE

IN ANOTHER JURISDICTION

APPLICANT INSTRUCTIONS

1. Complete Section 1. Enter your name as it appears on your Application (Form 1). Be sure to sign and date item 7.

2. Send this form with any fee required to the licensing authority of the state, province or country in which you passed the state licensure examination

to complete Section II and return this form directly to the Office of the Professions at the address at the end of this form.

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.)

Line 1

Line 2

Line 3

City

State

Zip Code

Country/

Province

If you entered a licensing examination in the United States using a different name, enter that name below:

last ___________________________________________ first _____________________________________ middle ______________________

Name of state, province or country where you are licensed and to which this form is being sent:

__________________________________________________________________________________________________

Date license was issued: _____ / _____ / _____

License number: _________________________________

mo.

day

yr.

I request and give my permission to the licensing authority listed in item 6 above to complete the information on this form and mail it to the New York

State Education Department and to release any other information required by the State Education Department in connection with my application for

licensure.

Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

VERIFICATION OF CHIROPRACTIC LICENSURE IS TO BE MADE ON NEXT PAGE

FORM 3, PAGE 1 OF 2

February 2004