Cytotechnologist/certified Histological Technician - Application For Licensure - The University Of The State Of New York The State Education Department - 2016 Page 2

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13.
14.
15.
14
Has any hospital or licensed facility or clinical laboratory restricted or terminated your professional training, employment, or privileges or
have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures?
Yes
No
NOTE: If you answer "Yes" to any questions numbered 10-14, submit a letter giving a complete detailed explanation. Include copies of any court records including a
Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. If the court can no longer provide documentation, you must
request, from the court, a letter stating why they cannot provide the documents.
15
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 Date 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 (in the original language): ___________________________________________________________________________
Date degree awarded: _______ / _______
mo.
yr.
Graduate Study/Advanced Certificate
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of degree or advanced certificate (in the original language): ________________________________________________________
Date degree or advanced certificate awarded: _______ / _______
mo.
yr.
16
Yes
No
Do you now hold, or have you ever held, a license or certificate to practice any profession in any jurisdiction?
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 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
17.
Cytotechnologist/Certified Histological Technician Form 1, Page 2 of 4, Rev. 8/16

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