Ophthalmic Dispensing Form 2 - Certification Of Professional Education In Ophthalmic Dispensing - New York State Education Department Page 2
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2SECTION II : CERTIFICATION OF EDUCATION
INSTRUCTIONS TO INSTITUTION: Please complete:
1.
Either Part A or Part B as appropriate; AND
2.
Part C
Please sign and date the certification and return this form directly to the Office of the Professions at the address shown below. DO NOT RETURN
THIS FORM TO THE APPLICANT.
PART A
– REGISTERED/ACCREDITED PROGRAMS
To be completed by those schools whose ophthalmic dispensing program is, or was at time the degree was awarded:
•
Registered by the New York State Education Department as licensure qualifying,
OR
•
Accredited by the Commission on Opticianry Accreditation (COA).
It is hereby certified that: _____________________________________________________________________________________
(Name of applicant)
has satisfactorily completed all requirements for the degree of _______________________________________________________
(Title of degree)
whether or not the diploma has actually been awarded.
Date all requirements for degree were met _____ / _____ / _____.
mo.
day
yr.
PART B
– NON-APPROVED PROGRAMS
NOTE:
Please attach an official transcript (with dates of attendance, courses completed and grades), a syllabus of the course of study (if not
previously submitted), and a list of clinical education completed (including required length).
To be completed by those schools whose ophthalmic dispensing program is not, or was not, at time the degree was awarded:
•
Registered by the New York State Education Department as licensure qualifying,
OR
•
Accredited by the Commission on Opticianry Accreditation (COA).
It is hereby certified that: _____________________________________________________________________________________
(Name of applicant)
was awarded the degree of ____________________________________________________ on the date of _____ / _____ / _____
(Title of degree)
mo.
day
yr.
Date all requirements for degree were met _____ / _____ / _____.
mo.
day
yr.
PART C
- CERTIFICATION: Note: Certification is not acceptable unless dated and submitted after the applicant’s graduation.
I hereby certify that to the best of my knowledge and belief the foregoing is a true statement of the education record of the individual named
on this form.
Signature of Registrar or designee: ______________________________________________________ Date _____ / _____ / _____
mo.
day
yr.
Type or print name: __________________________________________________________________
Title or official position: _______________________________________________________________
(INSTITUTION SEAL)
Institution: _________________________________________________________________________
Address: __________________________________________________________________________
Telephone: _________________________________ Fax: ___________________________________
E-mail: ____________________________________________________________________________
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Ophthalmic Dispensing
Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Ophthalmic Dispensing Form 2, Page 2 of 2, Rev. 12/04
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