Clinical Laboratory Technologist/technician Form 2 - Certification Of Professional Education
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1
21.
2.
3.
4.
5.
6.
7.
8.
9.
The University of the State of New York
Clinical Laboratory
THE STATE EDUCATION DEPARTMENT
Technologist/Technician
Office of the Professions
Division of Professional Licensing Services
Form 2
Check one:
Clinical Laboratory Technologist
Certified Clinical Laboratory Technician
Certification of Professional Education
Applicant Instructions
1. Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Sign and date item 9.
2. Send the entire form to the institution(s) you attended and ask the registrar to complete the appropriate parts of Section II and forward
both pages of the form directly to the Office of the Professions at the address at the end of this form. Be sure to include any fee
required by the institution. This form will not be accepted if submitted by the applicant.
3. An official transcript or marksheets are required if you completed a program that is not registered by the Department as licensure
qualifying at the time of your graduation.
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 Name As It Appears On Your Application for Licensure (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 your name as it appears on your degree or advanced certificate.
Name: ______________________________________________________________________________________________________
6
School attended: ______________________________________________________________________________________________
(Name)
(city/state or country)
7
Name of degree/advanced certificate: ___________________________________________________________________________
8
Date of degree/advanced certificate : ________ / ________ / ________
mo.
day
yr.
9
I request and give my permission to the school listed in item 6 above to complete Section II of this form and mail it to the New York
State 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
mo.
day
yr.
Clinical Laboratory Technologist/Technician Form 2, Page 1 of 2, Rev. 3/16
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