Transcription of Application for Licensure - State Education …
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Application for Licensure - State Education …
- Registered Physician Assistant Form 1 The University of the State of New York THE State Education DEPARTMENT Office of the Professions Division of Professional Licensing Services Application for LicensureApplicants Must Complete All Four Pages Of This Application In Ink Department Use Only NYS License Number Date Issued Initials 2 Social Security Number (Leave this blank if you do not have a Social Security Number) 3 Birth Date Month Day Year Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever voluntarily or involuntarily resigned or wi
www.op.nysed.gov NO Y - Registered Physician Assistant Form 1 The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions
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