Looking for a U.s. Department Of Education Forms And Templates? Download it for free!

Mental Health Counselor Application For Licensure - The University Of The State Of New York The State Education Department - 2016 Page 4

21. Gender and Ethnicity (This item is optional)

Information on gender and ethnicity is sought solely to allow the New York State Education Department to collect and analyze data

concerning diversity in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and

program evaluation purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for

licensure.

Gender

Male

Female

Ethnicity

White (not Hispanic)

Black (not Hispanic)

Asian

Hispanic

Native American

22. Education Program Review

I give permission to the New York State Education Department to release my examination results to my professional school for the

confidential purposes of program review and institution research and planning. I may rescind this authority at any time by notifying the

Division of Professional Licensing Services in writing.

Yes

Please initial

23. Child Abuse Identification and Reporting Coursework Requirement (check one)

I graduated from a NYS registered program and completed the coursework during my studies.

I completed the child abuse coursework and have enclosed a certificate of completion from an approved provider

I completed the child abuse coursework online and the approved provider will report that to you electronically.

I am filing for an exemption to the requirement and have enclosed the Certification of Exemption (Form 1CE*).

*Form 1CE is available on the Office of the Professions’ Web site at

24. Affidavit with Acknowledgement (notarization required)

Applicant

I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I

understand that any false or misleading information in, or in connection with, my application may be cause for denial or loss of licensure

and may result in criminal prosecution. This form must be signed and dated in the presence of a Notary Public.

Applicant's Signature

Date

Notary

State of

County of

On the

day of

in the year

before me, the above signed,

personally appeared

, personally known to me or proved to me on the basis

Applicant name

of satisfactory evidence to be the individual whose name is subscribed to this application and acknowledged to me that he/she executed

the application and swore that the statements made by him/her in the application and all supporting materials are true, complete, and

correct.

Notary Public's Signature

Notary Stamp

Notary ID number

Expiration Date

Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,

NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.

Mental Health Counselor Form 1, Page 4 of 4, Revised 10/17

Reset Form

Mental Health Counselor Application For Licensure - The University Of The State Of New York The State Education Department - 2016 Page 4

Related Articles

Related forms

Related Categories