Authorization for Verification of Academic Records/Transcripts

Transcription

1 Credetial Verificatio Service for New York State Authorizatio for Verificatio of Academic Records/Trascripts CGFNS Iteratioal P.O. Box 8628, Philadelphia, Pesylvaia USA Phoe: +1 (215) extesio 602 Web: Dear school official I have applied to the New York State Educatio Departmet for licesure as a. That departmet has authorized CGFNS Iteratioal to obtai my official academic records/trascripts. Please sed my official academic records/ trascripts directly to CGFNS Iteratioal. My iformatio appears below. My CGFNS ID umber (if kow) Order umber (if kow) My ame whe I atteded your school, Eglish spellig My ame whe I atteded your school, ative laguage spellig My curret ame (if differet tha above), Eglish spellig My curret ame (if differet tha above), ative laguage spellig The school where I received my post-secodary (tertiary) educatio, Eglish spellig The school where I received my post-secodary (tertiary) educatio, ative laguage spellig Attedace dates: From / to / My birth date / / Moth/Year Moth/Year School s curret mailig address My attestatio I hereby authorize CGFNS to obtai ay ad all documets ad/or iformatio regardig my academic records/trascripts. I also authorize CGFNS to disclose certai iformatio about me to the New York State Educatio Departmet, to ay perso or orgaizatio that I desigate i writig ad ay other recipiet that CGFNS believes has a legitimate iterest i receivig it (such as govermet agecies or potetial employers). CGFNS may disclose the iformatio ad documets pertaiig to my academic records/trascripts, the status of ay reports, evaluatios or verificatios prepared by CGFNS, ay other iformatio obtaied by CGFNS ad the results ad reasos for ay actio that CGFNS may take agaist me. My sigature Date / / Revised April 2011 Credetial Verificatio Service for New York State Applicatio Hadbook 15

2 Credetial Verificatio Service for New York State Authorizatio for Verificatio of Academic Records/Trascripts CGFNS Iteratioal P.O. Box 8628, Philadelphia, Pesylvaia USA Phoe: +1 (215) extesio 602 Web: Dear school official I have applied to the New York State Educatio Departmet for licesure as a. That departmet has authorized CGFNS Iteratioal to obtai my official academic records/trascripts. Please sed my official academic records/ trascripts directly to CGFNS Iteratioal. My iformatio appears below. My CGFNS ID umber (if kow) Order umber (if kow) My ame whe I atteded your school, Eglish spellig My ame whe I atteded your school, ative laguage spellig My curret ame (if differet tha above), Eglish spellig My curret ame (if differet tha above), ative laguage spellig The school where I received my post-secodary (tertiary) educatio, Eglish spellig The school where I received my post-secodary (tertiary) educatio, ative laguage spellig Attedace dates: From / to / My birth date / / Moth/Year Moth/Year School s curret mailig address My attestatio I hereby authorize CGFNS to obtai ay ad all documets ad/or iformatio regardig my academic records/trascripts. I also authorize CGFNS to disclose certai iformatio about me to the New York State Educatio Departmet, to ay perso or orgaizatio that I desigate i writig ad ay other recipiet that CGFNS believes has a legitimate iterest i receivig it (such as govermet agecies or potetial employers). CGFNS may disclose the iformatio ad documets pertaiig to my academic records/trascripts, the status of ay reports, evaluatios or verificatios prepared by CGFNS, ay other iformatio obtaied by CGFNS ad the results ad reasos for ay actio that CGFNS may take agaist me. My sigature Date / / Revised April 2011 Credetial Verificatio Service for New York State Applicatio Hadbook 15

3 Credetial Verificatio Service for New York State Authorizatio for Validatio of Licese/Registratio CGFNS Iteratioal P.O. Box 8628, Philadelphia, Pesylvaia USA Phoe: +1 (215) extesio 602 Web: Dear licesig authority I have applied to the New York State Educatio Departmet for licesure as a. That departmet has authorized CGFNS Iteratioal to obtai official validatio of my licese/registratio. Please sed a official validatio of my licese/registratio directly to CGFNS Iteratioal. My iformatio appears below. My CGFNS ID umber (if kow) Order umber (if kow) Licesig authority s ame Licesig authority s address My curret ame, Eglish spellig My curret ame, ative laguage spellig My licese/registratio was issued uder the ame (if differet tha above), Eglish spellig My licese/registratio was issued uder the ame (if differet tha above), ative laguage spellig My licese/registratio umber My birth date / / The school where I received my post-secodary (tertiary) educatio, Eglish spellig The school where I received my post-secodary (tertiary) educatio, ative laguage spellig Attedace dates: From to Moth/Year Moth/Year My coutry/citize idetificatio umber (if applicable) My attestatio I hereby authorize CGFNS to obtai ay ad all documets ad/or iformatio regardig my licese/registratio. I also authorize CGFNS to disclose certai iformatio about me to the New York State Educatio Departmet, to ay perso or orgaizatio that I desigate i writig ad ay other recipiet that CGFNS believes has a legitimate iterest i receivig it (such as govermet agecies or potetial employers). CGFNS may disclose the iformatio ad documets pertaiig to my licese/registratio, the status of ay reports, evaluatios or verificatios prepared by CGFNS, ay other iformatio obtaied by CGFNS ad the results ad reasos for ay actio that CGFNS may take agaist me. My sigature Date / / Revised April 2011 Credetial Verificatio Service for New York State Applicatio Hadbook 16

4 Credetial Verificatio Service for New York State Authorizatio for Validatio of Licese/Registratio CGFNS Iteratioal P.O. Box 8628, Philadelphia, Pesylvaia USA Phoe: +1 (215) extesio 602 Web: Dear licesig authority I have applied to the New York State Educatio Departmet for licesure as a. That departmet has authorized CGFNS Iteratioal to obtai official validatio of my licese/registratio. Please sed a official validatio of my licese/registratio directly to CGFNS Iteratioal. My iformatio appears below. My CGFNS ID umber (if kow) Order umber (if kow) Licesig authority s ame Licesig authority s address My curret ame, Eglish spellig My curret ame, ative laguage spellig My licese/registratio was issued uder the ame (if differet tha above), Eglish spellig My licese/registratio was issued uder the ame (if differet tha above), ative laguage spellig My licese/registratio umber My birth date / / The school where I received my post-secodary (tertiary) educatio, Eglish spellig The school where I received my post-secodary (tertiary) educatio, ative laguage spellig Attedace dates: From to Moth/Year Moth/Year My coutry/citize idetificatio umber (if applicable) My attestatio I hereby authorize CGFNS to obtai ay ad all documets ad/or iformatio regardig my licese/registratio. I also authorize CGFNS to disclose certai iformatio about me to the New York State Educatio Departmet, to ay perso or orgaizatio that I desigate i writig ad ay other recipiet that CGFNS believes has a legitimate iterest i receivig it (such as govermet agecies or potetial employers). CGFNS may disclose the iformatio ad documets pertaiig to my licese/registratio, the status of ay reports, evaluatios or verificatios prepared by CGFNS, ay other iformatio obtaied by CGFNS ad the results ad reasos for ay actio that CGFNS may take agaist me. My sigature Date / / Revised April 2011 Credetial Verificatio Service for New York State Applicatio Hadbook 16

5 14 Terms ad Coditios of the CGFNS Credetial Verificatio Service for New York State This sectio clarifies CGFNS s obligatios ad your obligatios regardig the Credetial Verificatio Service for New York State. It also explais how this service is delivered. CGFNS may choose to review oly the documets it cosiders relevat to this applicatio. Verificatio will ot be performed util CGFNS receives a completed, siged ad otarized* applicatio, full paymet ad appropriate authorizatio forms. Fees are subject to chage ad are foud at Ay paymet set to CGFNS will be applied first to ay upaid balace from previous orders for products or services before it is applied as paymet for a ewer order. The respose time for Caadia applicats is limited to 90 days. For all other coutries it is limited to 180 days. Whe the respose time has elapsed a fial review is performed ad a report is prepared ad set to the New York State Educatio Departmet. If you would like to be verified for New York State for aother occupatio, you will have to complete a etirely ew applicatio. No refud is give after a applicatio is submitted. Documets that CGFNS receives for its other services caot be used for the Credetial Verificatio Service for New York State. If your applicatio has bee forged, altered or falsified, that iformatio will be provided i the report to the New York State Educatio Departmet. * Autheticated, legalized or otarized by the coutry s approved chaels for autheticatio 15 Attestatio Please ote: Each applicat must sig his/her full ame i Eglish o the applicat s sigature lie. I certify that all iformatio which CGFNS has received as part of this applicatio or i the past, from me or from a third party o my behalf, is true ad complete. I also certify that all documets which have bee submitted to CGFNS for ay purpose have ot bee falsified, altered or tampered with by ay perso. I uderstad that CGFNS ad others will rely o this applicatio ad o the documets ad iformatio submitted, ad that if ay of it is falsified, altered or tampered with, or if I misrepreset a copy as a origial, CGFNS may take actio agaist me as it deems appropriate, icludig barrig me from participatio i ay CGFNS programs or to otherwise take actio agaist me as appropriate. The cosequeces could adversely affect my professioal licese, immigratio status, employmet ad other matters, from which I release CGFNS from all liability. I authorize CGFNS to disclose the iformatio ad documets i this applicatio, the status of ay reports or evaluatios prepared by CGFNS, ay other iformatio obtaied by CGFNS ad the results ad reasos for ay adverse actio take agaist me by CGFNS, to ay perso or orgaizatio I desigate i writig or to ay other recipiet which CGFNS may determie has a legitimate iterest i receivig the same, such as govermet agecies or potetial employers. You must sig ad date this applicatio i order for it to be processed. Your sigature Sig etire ame CGFNS ID umber Prit your ame Date Moth / Day / Year Notary (autheticatig official) sigature Sig etire ame Prit ame of otary Date Moth / Day / Year Mail the completed applicatio ad paymet to CGFNS Iteratioal, PO Box 8628, Philadelphia, PA USA Copyright CGFNS. All rights reserved. Revised April 2011 Credetial Verificatio Service for New York State Applicatio Hadbook 14

6 22 CHILD ABUSE IDENTIFICATION AND REPORTING COURSEWORK REQUIREMENT RN Applicats Oly (check oe): I graduated from a NYS registered ursig program after September 1, 1990 ad completed the coursework durig my studies. I completed the child abuse coursework ad have eclosed a certificate of completio from a approved provider. I completed the child abuse coursework olie ad the approved provider will report that to you electroically. I am filig for a exemptio to the requiremet ad have eclosed the Certificatio of Exemptio (Form 1CE*). *Form 1CE is available o the Office of the Professios Web site at 23 INFECTION CONTROL TRAINING REQUIREMENT (check oe): I graduated from a NYS registered ursig program after September 1, 1993 ad completed the ifectio cotrol traiig durig my studies. I completed the ifectio cotrol traiig ad have eclosed a certificate of completio from a approved provider. I completed the ifectio cotrol traiig olie ad the approved provider will report that to you electroically. I am filig for a exemptio to the requiremet ad have eclosed a Attestatio of Ifectio Cotrol Traiig (Form 1IC*). *Form 1IC is available o the Office of the Professios Web site at 24 EDUCATION PROGRAM REVIEW I give permissio to the New York State Educatio Departmet to release my examiatio results to my professioal school for the cofidetial purposes of program review ad istitutio research ad plaig. I may rescid this authority at ay time by otifyig the Divisio of Professioal Licesig Services i writig. Yes No Please iitial: 25 GENDER AND ETHNICITY: (This item is optioal.) Iformatio o geder ad ethicity is sought solely to allow the New York State Educatio Departmet to collect ad aalyze data cocerig diversity i the licesed professios. The ethic ad geder data you provide will be used oly for statistical, research, ad program evaluatio purposes. It will ot be released to the public. This iformatio has absolutely o bearig o your qualificatio for licesure. GENDER: Male Female ETHNICITY: White (ot Hispaic) Black (ot Hispaic) Asia Hispaic Native America 26 AFFIDAVIT WITH ACKNOWLEDGMENT (Notarizatio required.) Applicat I declare ad affirm that the statemets made i this applicatio, icludig accompayig documets, are true, complete ad correct. I uderstad that ay false or misleadig iformatio i, or i coectio with, my applicatio may be cause for deial or loss of licesure ad may result i crimial prosecutio. Applicat s sigature Date / / Notary State of Couty of O the day of i the year before me, the udersiged, persoally appeared, persoally kow to me or proved to me o the basis of satisfactory evidece to be the idividual whose ame is subscribed to this applicatio ad ackowledged to me that he/she executed the applicatio ad swore that the statemets made by him/her i the applicatio ad all supportig materials are true, complete, ad correct. Notary Public s sigature Notary ID umber Expiratio date / / Notary Stamp Mail this form ad appropriate fee to: New York State Educatio Departmet, Office of the Professios, PO Box 22063, Albay, NY DO NOT SEND CASH. Make check or moey order payable to the New York State Educatio Departmet. Nurse Form 1, Page 4 of 4, Rev. 4/11

7 Form 1CE The Uiversity of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professios Divisio of Professioal Licesig Services 89 Washigto Aveue Albay, NY CERTIFICATION OF EXEMPTION IDENTIFICATION AND REPORTING CHILD ABUSE ad MALTREATMENT TRAINING Applicats for licesure ad licesees applyig for re-registratio as physicias, chiropractors, detists, registered urses, podiatrists, optometrists, psychologists, detal hygieists, licesed master social workers, licesed cliical social workers, creative arts therapists, marriage ad family therapists, metal health couselors, ad psychoaalysts must complete two hours of Departmet approved coursework or traiig i the idetificatio ad reportig of child abuse ad maltreatmet. A limited exemptio from this requiremet is available if the ature of the applicat's/licesee's practice excludes cotact with childre. Ay licesee who asks for a exemptio must otify the Departmet i writig, withi 30 days, whe the ature of the practice chages ad a exemptio is o loger valid. APPLICANT INSTRUCTIONS 1. If you are certai that you qualify for a exemptio, complete items 1-6 by pritig clearly i ik i the spaces provided. Be sure to sig ad date Item 7 2. Sed the completed form to the address show above to the attetio of the uit for your professio (for example: Attetio Medicie Uit). See item 6 for listig. Properly completed forms will be accepted. You will oly receive otice from the Departmet if a request is isufficiet to grat a exemptio. Please retai a photocopy of this Certificatio of Exemptio. 1 Social Security Number (Leave this blak if you do ot have a U.S. Social Security Number) 5 N.Y.S. Licese Number (If applicable) 2 Birth Date Moth Day Year 3 Prit Your Name Exactly As It Appears O Your Licesure Applicatio Or Registratio Last First Middle 4 Mailig Address (You must otify the Departmet promptly of ay address or ame chages.) Lie 1 Lie 2 Lie 3 City 6 Professio (check oe) Medicie Chiropractic Detistry Detal Hygiee Registered Nurse Podiatry Optometry Psychology Licesed Master Social Worker Licesed Cliical Social Worker Creative Arts Therapist Marriage ad Family Therapist Metal Health Couselor Psychoaalyst State Coutry/ Provice Zip Code 7 ATTESTATION (b) The departmet may exempt a applicat or licesee from the coursework or traiig requiremet of subdivisio (a) of this sectio upo receipt of a writte applicatio for such exemptio establishig that there would be o eed to complete the coursework or traiig because the ature of the applicat's/licesee's practice excludes cotact with childre. It is the professioal resposibility of the licesee who holds a exemptio to otify the departmet i writig, withi 30 days, whe the ature of the practice chages to the extet that the basis for exemptio ceases to exist. I, the udersiged, have read regulatio 59.12(b) above ad the explaatio o this form. I uderstad the terms ad coditios cotaied therei, ad hereby declare that the ature of my practice is such that I do ot treat or otherwise have professioal cotact either with childre uder the age of 18 years or persos 18 years of age ad older with a hadicappig coditio who reside i a residetial care school or facility. Therefore, I claim a exemptio from the required traiig i child abuse ad maltreatmet idetificatio ad reportig pursuat to Sectio 59.12, Regulatios of the Commissioer. I also uderstad that should the ature of my practice chage to the extet that the basis for the exemptio ceases to exist, I am obligated to otify the departmet i writig ad complete the required traiig withi 30 days. I further uderstad that a false statemet o this documet may be cause for deial or loss of licesure ad may result i crimial prosecutio. Applicat sigature Date Certificatio of Exemptio Form 1CE, Rev. 01/05

8 Form 1CE The Uiversity of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professios Divisio of Professioal Licesig Services 89 Washigto Aveue Albay, NY CERTIFICATION OF EXEMPTION IDENTIFICATION AND REPORTING CHILD ABUSE ad MALTREATMENT TRAINING Applicats for licesure ad licesees applyig for re-registratio as physicias, chiropractors, detists, registered urses, podiatrists, optometrists, psychologists, detal hygieists, licesed master social workers, licesed cliical social workers, creative arts therapists, marriage ad family therapists, metal health couselors, ad psychoaalysts must complete two hours of Departmet approved coursework or traiig i the idetificatio ad reportig of child abuse ad maltreatmet. A limited exemptio from this requiremet is available if the ature of the applicat's/licesee's practice excludes cotact with childre. Ay licesee who asks for a exemptio must otify the Departmet i writig, withi 30 days, whe the ature of the practice chages ad a exemptio is o loger valid. APPLICANT INSTRUCTIONS 1. If you are certai that you qualify for a exemptio, complete items 1-6 by pritig clearly i ik i the spaces provided. Be sure to sig ad date Item 7 2. Sed the completed form to the address show above to the attetio of the uit for your professio (for example: Attetio Medicie Uit). See item 6 for listig. Properly completed forms will be accepted. You will oly receive otice from the Departmet if a request is isufficiet to grat a exemptio. Please retai a photocopy of this Certificatio of Exemptio. 1 Social Security Number (Leave this blak if you do ot have a U.S. Social Security Number) 5 N.Y.S. Licese Number (If applicable) 2 Birth Date Moth Day Year 3 Prit Your Name Exactly As It Appears O Your Licesure Applicatio Or Registratio Last First Middle 4 Mailig Address (You must otify the Departmet promptly of ay address or ame chages.) Lie 1 Lie 2 Lie 3 City 6 Professio (check oe) Medicie Chiropractic Detistry Detal Hygiee Registered Nurse Podiatry Optometry Psychology Licesed Master Social Worker Licesed Cliical Social Worker Creative Arts Therapist Marriage ad Family Therapist Metal Health Couselor Psychoaalyst State Coutry/ Provice Zip Code 7 ATTESTATION (b) The departmet may exempt a applicat or licesee from the coursework or traiig requiremet of subdivisio (a) of this sectio upo receipt of a writte applicatio for such exemptio establishig that there would be o eed to complete the coursework or traiig because the ature of the applicat's/licesee's practice excludes cotact with childre. It is the professioal resposibility of the licesee who holds a exemptio to otify the departmet i writig, withi 30 days, whe the ature of the practice chages to the extet that the basis for exemptio ceases to exist. I, the udersiged, have read regulatio 59.12(b) above ad the explaatio o this form. I uderstad the terms ad coditios cotaied therei, ad hereby declare that the ature of my practice is such that I do ot treat or otherwise have professioal cotact either with childre uder the age of 18 years or persos 18 years of age ad older with a hadicappig coditio who reside i a residetial care school or facility. Therefore, I claim a exemptio from the required traiig i child abuse ad maltreatmet idetificatio ad reportig pursuat to Sectio 59.12, Regulatios of the Commissioer. I also uderstad that should the ature of my practice chage to the extet that the basis for the exemptio ceases to exist, I am obligated to otify the departmet i writig ad complete the required traiig withi 30 days. I further uderstad that a false statemet o this documet may be cause for deial or loss of licesure ad may result i crimial prosecutio. Applicat sigature Date Certificatio of Exemptio Form 1CE, Rev. 01/05

9 Form 1IC The Uiversity of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professios Divisio of Professioal Licesig Services Registratio/Fee Uit 89 Washigto Aveue Albay, NY ATTESTATION OF INFECTION CONTROL TRAINING INSTRUCTIONS Complete Items 1-8 ad retur this form to the address prited above. Keep a photocopy of this completed ad siged form with other pertiet documetatio (i.e. copy of ay course completio certificate) i your persoal files. 1 SOCIAL SECURITY NUMBER (Leave this blak if you do ot have a U.S. Social Security Number) 2 BIRTH DATE mo. day yr. 3 PRINT FULL NAME EXACTLY AS IT APPEARS ON YOUR APPLICATION 4 LICENSE NUMBER Last First Middle 5 ADDRESS 7 Apt./Bldg. Street City State Provice/Coutry If ot U.S. INFECTION CONTROL TRAINING Zip Code Complete either sectio 1 or sectio 2 below: 6 CHECK YOUR PROFESSION DENTISTRY DENTAL HYGENE LIC. PRACT. NURSING REG. PROF. NURSING NURSE PRACTITIONER OPTOMETRY PODIATRY Sectio 1. COMPLIANCE BY COMPLETION OF APPROVED COURSE WORK. Withi the four years prior to the date of this attestatio I completed approved ifectio cotrol course work appropriate to my professioal practice give by: / / Provider ame mo. day yr. Sectio 2. EXEMPTION BASED ON LOCATION, NATURE OF PRACTICE, OR EQUIVALENT COURSE WORK. (check oe) (a) I will ot be egaged i the practice of my professio withi New York State durig the period idicated o my registratio applicatio. OR (b) The ature of my practice does ot require the use of ifectio cotrol techiques or barrier precautios. (c) I uderstad that, if I retur to my professioal practice i New York State or chage the ature of my practice thus requirig the use of ifectio cotrol techiques, I will iform the Educatio Departmet i writig withi 30 days ad, withi 90 days of the chage i practice, both obtai the required course work ad otify the Departmet of my compliace with this requiremet. OR I am exempt from the ifectio cotrol course work requiremet for the duratio of my ext registratio period because, withi the four years prior to the date of this attestatio, I completed ifectio cotrol course work appropriate to my professioal practice that covered all six core elemets cited i the istructios. I will maitai, for the ext four years, documetatio of the ifectio cotrol course cotet, icludig syllabi ad curricular materials, ad, if traiig was take outside a professioal program, a certificatio of course work completio that is dated ad siged by the provider. I completed this course work give by: / / Provider ame mo. day yr. 8 I swear that this attestatio is true ad I uderstad that ay false statemet may be cosidered fraud or perjury ad a form of professioal miscoduct which will result i discipliary actio agaist my professioal licese by the New York State Educatio Departmet. / / Sigature mo. day yr. July 2001

10 Form 1IC The Uiversity of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professios Divisio of Professioal Licesig Services Registratio/Fee Uit 89 Washigto Aveue Albay, NY ATTESTATION OF INFECTION CONTROL TRAINING INSTRUCTIONS Complete Items 1-8 ad retur this form to the address prited above. Keep a photocopy of this completed ad siged form with other pertiet documetatio (i.e. copy of ay course completio certificate) i your persoal files. 1 SOCIAL SECURITY NUMBER (Leave this blak if you do ot have a U.S. Social Security Number) 2 BIRTH DATE mo. day yr. 3 PRINT FULL NAME EXACTLY AS IT APPEARS ON YOUR APPLICATION 4 LICENSE NUMBER Last First Middle 5 ADDRESS 7 Apt./Bldg. Street City State Provice/Coutry If ot U.S. INFECTION CONTROL TRAINING Zip Code Complete either sectio 1 or sectio 2 below: 6 CHECK YOUR PROFESSION DENTISTRY DENTAL HYGENE LIC. PRACT. NURSING REG. PROF. NURSING NURSE PRACTITIONER OPTOMETRY PODIATRY Sectio 1. COMPLIANCE BY COMPLETION OF APPROVED COURSE WORK. Withi the four years prior to the date of this attestatio I completed approved ifectio cotrol course work appropriate to my professioal practice give by: / / Provider ame mo. day yr. Sectio 2. EXEMPTION BASED ON LOCATION, NATURE OF PRACTICE, OR EQUIVALENT COURSE WORK. (check oe) (a) I will ot be egaged i the practice of my professio withi New York State durig the period idicated o my registratio applicatio. OR (b) The ature of my practice does ot require the use of ifectio cotrol techiques or barrier precautios. (c) I uderstad that, if I retur to my professioal practice i New York State or chage the ature of my practice thus requirig the use of ifectio cotrol techiques, I will iform the Educatio Departmet i writig withi 30 days ad, withi 90 days of the chage i practice, both obtai the required course work ad otify the Departmet of my compliace with this requiremet. OR I am exempt from the ifectio cotrol course work requiremet for the duratio of my ext registratio period because, withi the four years prior to the date of this attestatio, I completed ifectio cotrol course work appropriate to my professioal practice that covered all six core elemets cited i the istructios. I will maitai, for the ext four years, documetatio of the ifectio cotrol course cotet, icludig syllabi ad curricular materials, ad, if traiig was take outside a professioal program, a certificatio of course work completio that is dated ad siged by the provider. I completed this course work give by: / / Provider ame mo. day yr. 8 I swear that this attestatio is true ad I uderstad that ay false statemet may be cosidered fraud or perjury ad a form of professioal miscoduct which will result i discipliary actio agaist my professioal licese by the New York State Educatio Departmet. / / Sigature mo. day yr. July 2001