Transcription of The University of the State of New York Licensed Clinical ...
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The University of the State of New York Licensed Clinical ...
The University of the State of New york The State Education Department Office of the Professions Division of Professional Licensing Services Clinical Social Worker Form 4 Applicant Experience RecordApplicant Instructions 1. Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 10. 2. For your experience to be considered, you must also complete Section I of Form 4B and forward the entire form and a copy of Appendix A to each supervisor you list in item 9 on this form. 1. Social Security Number(Leave this blank if you do not have a Social Security Number)2. Birth DateMonth DayYear3. Print Your Name Exactly As It Appears On Your Application for Licensure (Form 1)LastFirstMiddle4. Mailing Address (You must notify the Department promptly of any address or name changes)Line 1 Line 2 Line 3 CityStateZIP CodeCountry/ Province5. Telephone/Email AddressDaytime PhoneArea CodePhoneEmail Address (please print clearly)6.
The University of the State of New York The State Education Department Office of the Professions Division of Professional Licensing Services www.op.nysed.gov
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