Cytotechnologist/certified Histological Technician Form 4a - Certification Of Experience - The University Of The State Of New York The State Education Department - 2008
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21.
2.
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The University of the State of New York
Cytotechnologist
THE STATE EDUCATION DEPARTMENT
Certified Histological Technician
Office of the Professions
Division of Professional Licensing Services
Form 4A
Certification of Experience
(For Grandparenting Applicants Only)
Applicant Instructions
Complete Section I and forward this entire form to the Clinical Laboratory Director to complete Section II. Be sure to sign and date item 6.
This form may be photocopied, but both pages of all forms must be returned directly by the Clinical Laboratory Director and must bear an
original signature of the Clinical Laboratory Director.
Section I: Applicant Information
1
2
Social Security Number
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Name As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
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
5
Name of Clinical Laboratory Director I am asking to complete this form: ___________________________________________________
I have successfully practiced as a F cytotechnologist or F certified histological technician (see the definitions of practice for
cytotechnologist and certified histological technician on page 2); and
I am (check one):
F applying for licensure as a cytotechnologist under grandparenting method 1 (only report hours from December 31, 2002 through
December 31, 2007).
F applying for licensure as a cytotechnologist under grandparenting method 1A (only report hours prior to December 31, 2007).
F applying for licensure as a certified histological technician under grandparenting method 1 (only report hours prior to December
31, 2007).
F applying for licensure as a certified histological technician under grandparenting method 2 (only report hours from December
31, 2002 through December 31, 2007).
Duration of supervised experience:
Date beginning: _______
/ _______ /
_______
Date ending: _______ /
_______ /
_______
mo.
day
yr.
mo.
day
yr.
Total clock hours practicing: __________________
I request and give my permission to the individual listed in item 5 above to complete Section II of this form and mail it to the New York
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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. I also 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.
Applicant's signature: _____________________________________________________________ Date:_______ / _______ / _______
mo.
day
yr.
Cytotechnologist/Certified Histological Technician Form 4A, Page 1 of 2, (Rev. 9/08)
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