Clinical Laboratory Technologist/technician Form 4a - Certification Of Experience printable pdf download

The University of the State of New York

Clinical Laboratory

THE STATE EDUCATION DEPARTMENT

Technologist/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. 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

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

Name of Clinical Laboratory Director I am asking to complete this form: ___________________________________________________

I have successfully practiced as a F clinical laboratory technologist or F certified clinical laboratory technician (see the definitions of

practice for clinical laboratory technologist and certified clinical laboratory technician on page 2); and

I am (check one):

applying for licensure as a clinical laboratory technologist under grandparenting method 1 (only report hours prior to December 31, 2007).

applying for licensure as a clinical laboratory technologist under grandparenting method 2 (only report hours from December 31, 2002 through

December 31, 2007).

applying for licensure as a clinical laboratory technologist under grandparenting method 3 (only report hours from December 31, 2002 through

December 31, 2007).

applying for licensure as a clinical laboratory technologist under grandparenting method 6 (only report hours prior to July 1, 2009).

applying for licensure as a certified clinical laboratory technician under grandparenting method 1 (only report hours prior to December 31,

2007).

applying for licensure as a certified clinical laboratory 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 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.

Clinical Laboratory Technologist/Technician Form 4A, Page 1 of 2, (Rev. 9/08)