Mental Health Counselor Application For Licensure - The University Of The State Of New York The State Education Department - 2016 Page 2

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17. Please print clearly giving an accurate record of your educational preparation below. You must complete all information for all
schools/colleges/universities attended and diplomas and/or degrees received or your application will be considered incomplete.
Attach additional sheets if necessary.
Name of High School/Secondary School or GED Diploma Issuer
City
State/Province
Country
Number of years attended
Attendance from
to
mo.
yr.
mo.
yr.
Graduation date
or, GED Issued
mo.
yr.
mo.
yr.
Undergraduate College Study
Name of School
City
State/Province
Country
Major/Concentration
Number of years attended
Attendance from
to
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in original language)
Date Degree/Diploma/Certificate awarded
mo.
yr.
Graduate Program in Counseling
Name of School
City
State/Province
Country
Major/Concentration
Number of years attended
Attendance from
to
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in original language)
Date Degree/Diploma/Certificate awarded
mo.
yr.
Other Graduate Study
Name of School
City
State/Province
Country
Major/Concentration
Number of years attended
Attendance from
to
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in original language)
Date Degree/Diploma/Certificate awarded
mo.
yr.
18. Do you now hold, or have you ever held, a license or certificate to practice any profession* in any jurisdiction?
Yes
No
If yes, list each license/certificate, state or jurisdiction and provide appropriate information in the columns below. A Form 3 must be
submitted for each professional license/certificate listed unless it is a license/certificate issued by the New York State
Education Department. See the Applicant instructions on Form 3 for specific information about completing and submitting the
form.
*Profession is defined as professional titles licensed under New York State Education Law.
Date License/Certificate
License/Certificate
Limitations
Professional Title
State or Jurisdiction
Issued
Number
on License/Certificate
Mental Health Counselor Form 1, Page 2 of 4, Revised 10/17

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