Form 4e - Affidavit Of Professional Practice For Endorsement Applicants (Page 2 of 2) in pdf

Form 4e - Affidavit Of Professional Practice For Endorsement Applicants Page 2

Section II: Endorsing licensed Speech-Language Pathologist or Audiologist

Endorser Instructions: Complete this section and return the entire form directly to the Office of the Professions at the address below. Be

sure to sign and date the affirmation below.

Name of applicant: _____________________________________________________________________________________________

(Section I, item 3)

Endorser must check one of the following:

 I am a speech-language pathologist licensed and in good standing in the state or jurisdiction where applicant is licensed.

 I am an audiologist, licensed and in good standing in the state or jurisdiction where applicant is licensed.

I know him/her to be of good moral character, and recommend him/her to the State Board for Speech-Language Pathology and

Audiology and the Department as entirely worthy to be licensed to practice in the State of New York. I know that said applicant has

practiced as follows:

Date

Name and Address of Employer or Activity

From

Affirmation

I declare and affirm that the statements above are true, complete and accurate and further acknowledge that I am aware of the fact that,

pursuant to Penal Law §175.30, a person who knowingly offers a false instrument for filing to a public official or a public servant is guilty

of Offering a False Instrument for Filing in the 2nd Degree, a Class A Misdemeanor.

Signature of Endorser ______________________________________________________________ Date _______ / _______ / _______

mo.

day

yr.

Print name _______________________________________________________________________

Endorser Title ____________________________________________________________________

Title of Endorsee __________________________________________________________________

License number__________________________ ASHA number: ____________________________

State ____________________________________________________________________________

Address _________________________________________________________________________

________________________________________________________________________________

Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,

Speech-Language Pathology & Audiology Unit, 89 Washington Avenue, Albany, NY 12234-1000.

Speech-Language Pathology & Audiology Form 4E, Page 2 of 2, July 2015

Form 4e - Affidavit Of Professional Practice For Endorsement Applicants Page 2