Pharmacist Form 2 - Certification Of Professional Education - New York The State Education Department
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1
2
3FORM 2
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
PHARMACIST
Office of the Professions
Division of Professional Licensing Services
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1. Complete Section I. Enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 7.
2. Send this form to the pharmacy school you attended and ask them to complete the appropriate parts of Section II beginning on page 2 of this
form. Be sure to include any fee required by the school. The school completing Section II must return this form directly to the Office of the
Professions at the address at the end of the form. This form will not be accepted if submitted by the applicant.
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 FULL NAME EXACTLY 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
Print name under which degree was awarded: _____________________________________________________________________________
6
Professional School attended: _________________________________________________________________________________________
Address: __________________________________________________________________________________________________________
Title of degree: _______________________________________________________
Date degree was awarded: _____ / _____ / _____
I request and give my permission to the institution named in item 6 above to complete the information on this form and send any documentation
7
requested, including that requested on this form (e.g. an official transcript), to the New York State Education Department.
Applicant's signature: _____________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Rev. 2/16
FORM 2, PAGE 1 OF 3
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