Professional Engineering - Application For Licensure And First Registration - The University Of The State Of New York The State Education Department - 2011 Page 4

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21
EDUCATION REVIEW
I give permission to the New York State Education Department to release my examination results to my professional school
for the confidential purposes of program review and institution research and planning. I may rescind this authority at any
time by notifying the Division of Professional Licensing Services in writing.
Yes
No
Please initial: _____________
22
AFFIDAVIT WITH ACKNOWLEDGMENT
(Notarization required.)
APPLICANT
I 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.
Signature of the applicant: ___________________________________________________________________________
Date: __________ / __________ / __________
Month
Day
Year
NOTARY
State of __________________________________________ County of _______________________________________
On the ____________ day of ______________________ in the year __________ before me, the undersigned, personally
appeared __________________________, personally known to me or proved to me on the basis of satisfactory evidence
to be the individual whose name is subscribed to this application and acknowledged to me that he/she executed the
application and swore that the statements made by him/her in the application and all supporting materials are true,
complete, and correct.
Notary Public signature _____________________________________________________________________________
Notary ID number _______________________________
Notary Stamp
Expiration date __________ / __________ / __________
Month
Day
Year
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,
NY 12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Professional Engineering Form 1, Page 4 of 4, Rev. 4/11

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