Form 2ac - Certification Of Acupuncture Education Page 2
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2SECTION II : CERTIFICATION OF ACUPUNCTURE EDUCATION
INSTRUCTION TO SCHOOL: Please complete Part A or Part B of this section, sign the certifying statement, attach any additional information
required (if applicable) and send this form directly to the Office of the Professions at the address shown below. This form will not be accepted if
returned by the applicant or any other party.
Name of applicant ________________________________________________________________________________________________________
(Item 6, Section I)
New York State Registered/Approved Acupuncture Programs:
A.
The above named applicant has completed the following programs registered by the New York State Education Department as qualifying
for credit toward the 300 hours of acupuncture training required for certification to use acupuncture.
Program title: ___________________________________________________________________________________________________
All program requirements were met on: ______ / ______ / ______ Acupuncture credential was awarded on:
______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
Date
Title of Program
Hours of Credit
Non New York State Registered/Approved Acupuncture Program (Attach transcript showing content and hours):
B.
The above named applicant has completed the following program not registered by the New York State Education Department as
preparation for the practice of acupuncture.
Program title: _____________________________________________________
The program contained _______ hours of classroom work
The program contained _______ hours of supervised clinical training
Date of admission: _______ / _______ / _______
Date of Completion: _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Credential Awarded: _______________________________________ Date: _______ / _______ / _______
mo.
day
yr.
This program was approved by: ____________________________________________________________________________________
CERTIFICATION
I certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the individual named on this form.
Signature: ___________________________________________________________________ Date: _____ / _____ / _____
Type or print name: ___________________________________________________________
Title: _______________________________________________________________________
(SEAL)
School: _____________________________________________________________________
Address: ___________________________________________________________________
___________________________________________________________________
Telephone: _______________________________ Fax _______________________________
CERTIFICATION IS NOT ACCEPTABLE UNLESS
E-mail address: ______________________________________________________________
DATED AFTER GRADUATION.
Return this form
New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Medicine Board,
89 Washington Avenue, Albany, NY 12234-1000.
Directly to:
FORM 2AC, PAGE 2 OF 2
November 2002
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