Acupuncture Form 2b - Certification Of Professional Acupuncture Education Page 2
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2SECTION II: CERTIFCATION OF PROFESSIONAL ACUPUNCTURE EDUCATION
INSTRUCTIONS TO SCHOOL: Please complete this section of the form, sign the certifying statement, attach an official transcript, and send directly to
the Office of the Professions at the address at the end of the form. The official transcript must bear the original signature of the registrar and the original
seal of the school.
THIS FORM WILL NOT BE ACCEPTED IF RETURNED BY THE APPLICANT.
1.
Name of applicant: _____________________________________________________________________________________________
(See Number 5 on page 1)
2.
Professional School:
Name: _______________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
(street)
(city)
(state)
(zip code)
(country)
3.
Date of applicant's entrance, date of completion of studies or withdrawal from the school:
Entrance date: _______________________________
Completion/Withdrawal date: _______________________________
4.
Title of Degree/Diploma conferred: __________________________________
Date of conferral: ____________________________
5.
Please list the number of years of education required for admission to this program: ________________
6.
What was the credential/diploma submitted by the applicant named above for admission to your school? ________________________
7.
Was this a formal acupuncture program, of a minimum of 4,050 hours, which included: 1) at least 200 classroom instructional hours in the
biosciences including anatomy, physiology and pathology; 2) at least 600 classroom instructional hours in acupuncture principles, theory, and
techniques; and 3) at least 650 hours of supervised clinical acupuncture experience?
YES
NO
8.
FOR U.S. INSTITUTIONS ONLY:
Was this program accredited by the Accreditation Commission for Acupuncture and Oriental
YES
NO
Medicine (ACAOM) at the time the applicant was enrolled in such program?
9.
At the time of this student's enrollment, was this program accredited by another professional or
YES
NO
governmental agency?
If Yes, provide the name of the agency _______________________________________________________________________________
10.
FOR INSTITUTIONS LOCATED OUTSIDE THE U.S.:
What governmental agency accredited this acupuncture program at the time of this student's enrollment? __________________________
IMPORTANT: ATTACH OFFICIAL TRANSCRIPT, MARKSHEETS, OR OTHER RECORD, REPORTED IN CREDIT HOURS, SHOWING
COURSES STUDIED BY YEAR AND PASSED (WITH GRADES IF AVAILABLE) OF ALL COURSES TAKEN AT THE SCHOOL.
THE OFFICIAL TRANSCRIPT MUST BEAR THE ORIGINAL SIGNATURE OF THE REGISTRAR AND THE ORIGINAL SEAL OF THE
SCHOOL.
CERTIFICATION BY REGISTRAR
I certify that the information shown above is true and correct for the individual named in Section I, according to the educational
records of this office.
Signature: _________________________________________________________ Date: _______ / _______ / _______
Mo.
Day
Yr.
Print name: ________________________________________________________
Title: ______________________________________________________________
OFFICIAL
COLLEGE
School: ____________________________________________________________
SEAL
Telephone: _____________________ Fax: _______________________________
E-mail: ____________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Acupuncture Unit, 89
Washington Avenue, Albany, NY 12234-1000.
Acupuncture Form 2B, Page 2 of 2, Rev. 12/04
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