Verification Of Licensure In Another Jurisdiction {3R}

Restoration Form 3R 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 Verification of Licensure in Another Jurisdiction APPLICANT INSTRUCTIONS 1. 2. Complete Section I and II. Enter your name as it appears on your Application for Restoration of a Professional License (Form 1R). DO NOT RETURN THIS FORM WITH YOUR APPLICATION. Send this form to each state or country where you are licensed and request that they complete Section III on back. Be sure to include any fee(s) required. If additional forms are needed this form may be photocopied. You must provide verification of licensure and the status of your license from ALL jurisdictions where you are licensed. Verifications must be in English or otherwise submitted with an official translation. Section I: Applicant Information 1 Social Security Number (Leave this blank if you do not have a U.S. Social Security Number) 2 Birth Date Month Day Year 3 Print Full Name Last First Middle 4 Address Line 1 Line 2 Line 3 City State Zip Code 5 Print name of jurisdiction: _________________________________________________________________________________________________ Name under which you are licensed in the jurisdiction: __________________________________________________________________________ Date of Licensure: _______ / _______ / _______ License number: ____________________________ mo. day yr. Profession: ________________________________________________________________________ Section II: Applicant Release I request and authorize the above named jurisdiction to release any and all information pertaining to my license, including by not limited to, disciplinary actions and pending charges. Applicant's signature: Date: mo. / day / yr. Restoration Form 3R, Page 1 of 2, May 2006 American LegalNet, Inc. www.FormsWorkflow.com Section III: Other Jurisdiction's Certification. Instructions: To be completed by the licensing authority. Do not return to applicant. Return completed form to the address at the end of the form Has the applicant named in Section I been subject to any disciplinary action? Are there any charges pending against this individual? Yes Yes No No 1 A. B. If the answer to either of these questions is "yes", please attach all relevant information 2 License number: _________________________________________ Date issued: _______ / _______ / _______ mo. day yr. Expiration date of most recent registration: _______ / _______ / _______ is this license current? mo. day yr. Yes No I certify that the information shown above is true and correct according to the records of this office. Signature: ____________________________________________________________________________ Date: _______ / _______ / _______ mo day yr. Name: _______________________________________________________________________________ Title: _________________________________________________________________________________ (Board Seal) Jurisdiction: ___________________________________________________________________________ Telephone: ____________________________________ Fax: ___________________________________ E-mail: _______________________________________________________________________________ Section IV: Optional Comments. To be completed by the licensing authority. Comments: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Return to: The Office of the Professions, COP, West Wing, 2 Floor, 89 Washington Avenue, Albany, NY 12234-1000 Restoration Form 3R, Page 2 of 2, May 2006 American LegalNet, Inc. www.FormsWorkflow.com nd