Medical Physicist Form 4a - Verification Of Professional Experience
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1
2The University of the State of New York
Medical Physicist Form 4A
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Diagnostic Radiological
Division of Professional Licensing Services
89 Washington Avenue
Medical Health
Albany, NY 12234-1000
Medical Nuclear
Therapeutic Radiological
VERIFICATION OF PROFESSIONAL EXPERIENCE
Applicant Instructions
1.
Complete a separate Form 4A for each specialty area you are applying for.
2.
Complete Section 1. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date the attestation below.
3.
Forward this form and a copy of the instructions for Form 4A to the endorser who will attest to your professional practice of medical physics and request that
he/she complete Section II and return the form directly to the Office of the Professions at the address at the end of this form. Photocopy this form if you need
additional endorsers to verify the total number of years of professional practice required.
SECTION I: APPLICANT INFORMATION
Social Security Number:
Name:
Last
First
Middle
Birth Date:
Mailing Address: (You must notify the Department promptly of any address or name changes.)
Line 1
mo .
day
yr.
Line 2
Line 3
City
State
Zip Code
Country/
Province
Telephone:
Daytime Phone
E-Mail Address (Please print clearly)
Area Code
Number
Endorser’s Name
_________________________________________________________________________________________________
:
Experience described below was completed while you were employed by: _________________________________________________
Address:
Street
________________________________________________________________________________________
________________________________________________________________________________________
City
____________________________________________ State _____________ Zip code __________________
If licensed in the United States, indicate state or territory: __________________________________________________________________
Specialty area: ____________________________________________________________________________________________________
Report of Experience - Describe in the space below your medical physicist duties during your employment with the organization named above.
Beginning _____ / _____ / _____
Ending _____ / _____ / _____ or
Still employed by organization.
mo.
day
yr.
mo.
day
yr.
Specialty area: ______________________________________________________________________Clock hours in a calendar year: ______________
ATTESTATION
I hereby certify that the work experience described above and the time claimed for that experience are true and accurate and give permission
to the individual endorser named above to complete the information in Section II of this form and send it to the New York State Education
Department.
_______________________________________________________________________
______________________________________
Applicant's signature
Date
Medical Physicist Form 4A, Page 1 of 2, Rev. 09/04
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