Optometry Form 4a - Supporting Affidavit Of Professional Practice - New York The State Education Department

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The University of the State of New York
Optometry Form 4A
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
SUPPORTING AFFIDAVIT OF PROFESSIONAL PRACTICE
- FOR ENDORSEMENT APPLICANTS -
APPLICANT INSTRUCTIONS
1. Complete Section I in ink. Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 7.
2. Send both pages of this form to the licensed optometrist(s) who will attest to your professional practice for completion of Section II and the
certification.
Section I: Applicant Information
Birth Date
1
2
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Name Exactly As It Appears On Your Licensure Application (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
Date of Licensure: _______ / _______ / _______
mo.
day
yr.
In which jurisdiction? ___________________________________________________________________________________________________
6
Name of practice: ______________________________________________________________________________________________________
Practice address: ______________________________________________________________________________________________________
Exact Dates of practice:
From: _______ / _______ / _______
To: _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Licensed optometrist to which this form is being sent: __________________________________________________________________________
I request and give my permission to the licensed optometrist listed in item 6 to complete Section II of this form, release any other information
7
required by the State Education Department in connection with my application for licensure, and return this form directly to the State Education
Department at the address at the end of this form.
_____________________________________________________________________________________
_________________________
Applicant’s Signature
Date
Optometry Form 4A, Page 1 of 2, Rev. 08/05

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