Form 3 - Verification Of Out-Of-State Licensure, Registration And Examination
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1
2The University of the State of New York
Architect
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 3
Division of Professional Licensing Services
Verification of Out-Of-State Licensure, Registration and/or Examination
(Must be filed by all applicants who are or have been licensed in another jurisdiction
or want to verify passing parts of the licensing examination in another state)
Applicant Instructions
1.
Complete Section I in ink. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 8.
2.
Send this form to the out-of-state licensing authority. Be sure to include any fee required by that licensing authority. A separate form must be submitted from each jurisdiction in
which you passed the licensing examination(s).
(a)
If you are applying for admission to the exam, and have passed any division of the exam in another jurisdiction, send this form to any such jurisdiction and request that
they complete Section II.
(b)
If you are applying on the basis of direct endorsement, send this form to the jurisdiction where you were originally licensed or registered and ask that they complete
Section II.
3.
Request that each licensing authority send the completed Form 3 directly to the Office of the Professions at the address at the end of this form. This form will not be
accepted if submitted by the applicant.
Section I: Applicant Information
3
Social Security Number
3.
Print Name As It Appears On Your Application for Licensure (Form 1)
1
(Leave this blank if you do not have a U.S. Social
Security Number)
Last
First
Middle
2
4.
Mailing Address
4
(You must notify the Department promptly of any address or name changes.)
Birth Date
Line 1
Month
Day
Year
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
5.
If licensed by examination in the U.S., give state or territory: ____________________________________________________________
6.
Print or type your name in the exact form in which architecture registration or certification was issued:
6
_____________________________________________________________________________________________________________
7
7.
To the Architecture State Board of: _________________________________________________________________________________
Check the appropriate boxes:
I hereby make application for the transfer of examination grades and related information.
I am an Architect in your state. License number: _______________________________ Date issued: _______ / _______ / _______
mo.
day
yr.
8.
I request and give permission to the licensing authority to complete the information on this form and send any documentation requested,
8
including that requested on this form, to the New York State Education Department.
___________________________________________________________________________________ _______ / _______ / _______
Applicant’s Signature
mo.
day
yr.
Section II: Certification of Licensure
Instructions to Licensing Authority Official: Complete Section II, sign this form, and mail it directly to the Office of Professions at the
address at the end of this form. Do not return this form to the applicant. This form will not be accepted if returned by the applicant.
1.
a.
If applicant holds a current license to practice architecture in your state:
1
Expiration date of
License number _________________ Date issued ____________________ most recent registration ______________________
b.
Was there ever any disciplinary action against this license?
If so, please explain ________________________________________________________________________________________
c.
Are any disciplinary charges pending against this license?
If so, please explain ________________________________________________________________________________________
Architect Form 3, Page 1 of 2 (Rev. 8/09)
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