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20. I give permission to the New York State Education Department to release my examination results to my professional school for the

confidential purposes of program review and institution research and planning. I may rescind this authority at any time by notifying the

Division of Professional Licensing Services in writing.

Yes

 No

Please initial: _____________________

22. Affidavit With Acknowledgment (Notarization required.)

Applicant

I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I

understand that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure

and may result in criminal prosecution. This form must be signed and dated in the presence of a Notary Public.

In addition, if I am applying for licensure under grandparenting, I certify that I believe in good faith that I currently meet or will meet the

requirements for licensure by the specified completion dates.

I am also certifying that I have reviewed the rules and regulations of the New York State Department of Health and the U.S. Department

of Health and Human Services that are identified in the Additional Educational Requirements section in either the paper Application

Packet or under License Requirements on the Office of the Professions’ Web site at (This certification does not

apply to those applying for licensure as a clinical laboratory technologist under Methods 1, 4 or 5 or for licensure as a certified clinical

laboratory technician under Methods 1 or 3.)

Signature of the applicant: ______________________________________________________________________________________

Date __________ / __________ / __________

Month

Day

Year

Notary

State of __________________________________________________ County of __________________________________________

On the ____________ day of ______________________ in the year __________ before me, the above signed, personally appeared

__________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual

Applicant Name

whose name is subscribed to this application and acknowledged to me that he/she executed the application and swore that the

statements made by him/her in the application and all supporting materials are true, complete, and correct.

Notary Public signature _________________________________________________________________________________________

Notary ID number _______________________________

Notary Stamp

Expiration date __________ / __________ / __________

Month

Day

Year

Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY

12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.

Clinical Laboratory Technologist/Technician Form 1, Page 4 of 4, Rev. 6/16

Clinical Laboratory/technologist/technician - Application For Licensure - The University Of The State Of New York The State Education Department - 2016 Page 4