Cytotechnologist/certified Histological Technician - Certification Of Professional Education - The University Of The State Of New York The State Education Department - 2008 Page 2
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1
2Section II: Certification of Education
Instructions to Registrar:
1.
Complete Part A or Part B to document the applicant's education.
2.
Complete Part C (Certification) and return both pages of this form in an official school envelope with requested documents
directly to the Office of the Professions at the address at the end of the form. Do not return this form to the applicant. This
form will not be accepted if returned by the applicant.
Name of applicant: ________________________________________________________________________________________________
(Section I, item 5)
Part A - Cytotechnologist/Certified Histological Technician Program Registered by the New York State Education Department
(NYSED) as licensure qualifying: To be completed only by those schools whose cytotechnologist/certified histological technician
program was, at the time the degree was (or will be) awarded, registered by the New York State Education Department.
Completed the program on _______ / _______ / _______ and was awarded the degree/advanced certificate of
mo.
day
yr.
________________________________________________________________________ on the date of _______ / _______ / _______,
(Title of degree/advanced certificate)
mo.
day
yr.
OR
on _______ / _______ / _______ this institution determined that the above-named student met all requirements for the
mo.
day
yr.
degree/advanced certificate and the institution has agreed to award the degree/advanced certificate of
_____________________________________________________________________________________________________________
.
(Title of degree/advanced certificate)
Part B - All Other Programs. An official transcript or marksheet giving courses completed by year and grades and a syllabus or
description of the course of studies completed must be attached.
1.
Date of applicant's entrance, and either the applicant's date of completion of studies or withdrawal from the school:
Entrance date: ______ / ______ / ______
Completion date: ______ / ______ / ______
Withdrawal date: ______ / ______ / ______
mo.
day
yr.
mo.
day
yr.
mo.
day
yr.
2.
Title of degree/advanced certificate awarded: ________________________________________________________________________
3.
Date degree/advanced certificate awarded: _______ / _______ / _______
mo.
day
yr.
Name of accrediting body or official organization that recognizes this program: ______________________________________________
Date of Accreditation: _____________________________
Year
Address of accrediting body or official organization that recognizes this program: ____________________________________________
_____________________________________________________________________________________________________________
Part C - Certification
I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the
professional education of the individual named on this form.
Signature: _____________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Title or Official Position: __________________________________________________________
Institution: _____________________________________________________________________
Address: ______________________________________________________________________
(SEAL)
City: ____________________________ State ____________ Zip Code ____________________
Telephone: _______________________________ Fax: _________________________________
E-mail Address: _________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Clinical Laboratory Technology Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Cytotechnologist/Certified Histological Technician Form 2, Page 2 of 2, (Rev. 9/08)
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