Acupuncture Form 2b - Certification Of Professional Acupuncture Education

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Acupuncture Form 2B
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF PROFESSIONAL
ACUPUNCTURE EDUCATION
APPLICANT INSTRUCTIONS
1.
Complete Section 1. Enter your name as it appears on your licensure application (Form 1). Be sure to sign and date item 9.
2.
Send this form to each institution where you completed Medical/Acupuncture education.
Make copies as necessary. Be sure to include
any fee required by the school.
SECTION I: APPLICANT INFORMATION
Birth Date
1
2
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
Print Full Name Exactly As It Appears On Your Licensure Application (Form 1)
3
Last
First
Middle
Mailing Address:
(You must notify the Department promptly of any address or name changes.)
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print name under which you were registered at this professional school: ________________________________________________________
6
Secondary and/or preprofessional school attended: _____________________________________________________________________
(preceding professional school)
7
Professional school attended: _______________________________________________________________________
Address:
8
Title of degree/diploma: ____________________________________________
Date degree/diploma was awarded: _____ / _____ / _____
I request and give my permission to the school listed in item 7 above to complete Section II of this form and mail it to the New York State Education
9
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: _______________________________________________________________________ Date: _______ / _______ / _______
Mo.
Day
Yr.
Acupuncture Form 2B, Page 1 of 2, Rev. 12/04

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