Supporting Affidavit {4R}

Restoration Form 4R The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions Committee on the Professions nd West Wing, 2 Floor 89 Washington Avenue Albany, NY 12234-1000 Supporting Affidavit Applicant Instructions: Affiant Instructions: Complete items A, B and C and provide a copy to each of your affiants/references. Attach completed original of each affidavit to your restoration application. Complete items 1-5; sign the affidavit in the presence of a Notary Public; and return the form to the applicant. New York State Education Department Office of Professional Responsibility A. State Board for ______________________________________________________________________ In the Matter of the Application of B. ___________________________________________________________________________________ (Applicant's name) This affidavit is in support of an application for restoration of a professional license for the restoration of (his/her) license to practice C. as a _______________________________________________________________________________ in the State of New York. State of New York ) ) County of ____________________ ________ ) as: ___________________________________________________________________________________, being duly sworn deposes and says; (Affiant/reference name) 1. My name is _________________________________________________________________________. (Affiant/reference name) I reside at __________________________________________________________________________. (Affiant/reference address) My daytime telephone number including area code is ________________________________________. My occupation is _____________________________________________________________________. I am a licensed professional If yes: Yes No Profession: ___________________________________________ State: _________________ License Number: _____________________________ Is the license current? Yes No Date license issued: _______ / _______ / _______ Expiration date of last registration: _______ / _______ / _______ mo. day yr. mo. day yr. I make this affidavit in support of _________________________________________________________ application for restoration of (his/her) (Applicant's name) license to practice as a ________________________________________________________________ in the State of New York. Restoration Form 4R, Page 1 of 2, May 2006 American LegalNet, Inc. www.FormsWorkflow.com 2. I have known the applicant for __________ years and __________ months through the following contacts: ________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 3. It is my understanding that the applicant's license was revoked or surrendered because: ______________________________________________ (Provide a detailed statement of circumstances which led to revocation/surrender of license) _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 4. It is my understanding that the applicant has undertaken the following activities to rehabilitate (himself/herself): _____________________________ (Provide a detailed statement of activities) _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 5. I recommend that the applicant's license be restored because: ___________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _________________________________________________________________ (Affiant's signature) Sworn to before me this __________ day of ________________________________________, 20__________. Notary Public signature ______________________________________________________________________ Restoration Form 4R, Page 2 of 2, May 2006 American LegalNet, Inc. www.FormsWorkflow.com