Certified Histological Technician Form 4c - Certification Of Experience And Competence - 2008
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21.
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The University of the State of New York
Certified Histological Technician
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 4C
Division of Professional Licensing Services
Certification of Experience and Competence
(For Certified Histological Technician Applicants Using Grandparenting Method 1A Only)
(Applications using these methods will only be accepted if submitted by September 1, 2013)
Applicant Instructions
Complete Section I and forward this entire form to the Clinical Laboratory Director to complete Section II. 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 practiced as a certified histological technician for at least 6 months (at least 720 clock hours) as defined below and I am applying for
licensure under grandparenting method 1A (only report hours from December 31, 2004 through December 31, 2007).
Certified histological technician means a clinical laboratory practitioner who pursuant to established and approved protocols of the
department of health performs slide based histological assays, tests, and procedures and any other such tests conducted by a clinical
histology laboratory, including maintaining equipment and records and performing quality assurance activities relating to procedure
performance on histological testing of human tissue and which requires limited exercise of independent judgement and is performed
under the supervision of a laboratory supervisor, designate by the director of a clinical laboratory or under the supervision of the director
of the clinical laboratory.
Duration of supervised experience:
Date beginning: _______ / _______ / _______
Date ending: _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Total clock hours practicing histotechnology: __________________
6
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
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.
Certified Histological Technician Form 4C, Page 1 of 2, (Rev. 9/08)
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