Form 1ac-R - Application For Certification To Use Acupuncture
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1
2The University of the State of New York
Department Use Only
Form 1AC-R
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
APPLICATION FOR CERTIFICATION
TO USE ACUPUNCTURE
Applicants Must Complete Both Pages Of This Application In Ink
Applicant Instructions
All applicants for certification must complete this form in ink and submit it with the $150 certification
fee directly to the Office of the Professions at the mailing address at the end of this form. You must
answer all questions and provide all information requested unless otherwise indicated. Failure to
complete all required parts of the application will delay its review. Your signature on this form must be
notarized by a Notary Public.
NYS License Number
1
Check what you are applying for:
50
$150
AC
Dentistry
6
Telephone/E-Mail Address
60
$150
AC
Medicine
2
Daytime Phone
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Area Code
Phone Number
3
Birth Date
Month
Day
Year
E-Mail Address (Please print clearly)
4
Print Your Name Exactly As It Appears On Your Medical or Dental License
Last
First
Middle
7
New York State DMV ID Number
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
(Driver or Non-Driver ID)
Line 1
(Leave this blank if you do not have a
Line 2
New York State DMV ID Number)
Line 3
City
State
Zip Code
Country/
Province
8
New York State profession license number: ______________________________________
9
Have you previously applied for a New York State certificate to use acupuncture?
YES
NO
10
List Non-Registered New York State Acupuncture Programs completed.
Program Sponsor: ______________________________________________________________________ Hours of Instruction: _______________
Location of Program: ___________________________________________________________________ Date of Program: _____ / _____ / _____
mo.
day
yr.
Program Sponsor: ______________________________________________________________________ Hours of Instruction: _______________
Location of Program: ___________________________________________________________________ Date of Program: _____ / _____ / _____
mo.
day
yr.
Program Sponsor: ______________________________________________________________________ Hours of Instruction: _______________
Location of Program: ___________________________________________________________________ Date of Program: _____ / _____ / _____
mo.
day
yr.
Form 1AC-R, Page 1 of 2, Rev. 4/12
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