Form 4e - Affidavit Of Professional Practice For Endorsement Applicants
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1
2Form 4E
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Speech-Language Pathologist
Division of Professional Licensing Services
Audiologist
Affidavit of Professional Practice for Endorsement Applicants
Applicant Instructions
Complete Section I and forward this form to the licensed speech-language pathologist or audiologist who will endorse your licensure
application (the endorser must be licensed in the jurisdiction where you were employed). Be sure to sign and date item 7. Ask your
endorser to complete Section II and send the entire form directly to the address at the end of this form. This form will not be accepted if
returned by the applicant.
Section I: Applicant Information
1
2
1.
Social Security Number
2.
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
5
3.
Print Name as It Appears on Your Application for Licensure (Form 1)
6.
Telephone/E-Mail Address
Last
Daytime phone
First
Area Code
Phone
Middle
E-mail Address
(please print clearly)
4
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
6
Name of Endorser: _____________________________________________________________________________________________
Address of Endorser: ___________________________________________________________________________________________
Duration of Experience:
From: _______ / _______
To: _______ / _______
month
year
month
year
7
I request and give my permission to the individual 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 Signature
Date
Speech-Language Pathology & Audiology Form 4E, Page 1 of 2, July 2015
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