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The University of the State of New York Nurse Form 3 ...

The University of the State of New York The State Education Department Office of the Professions Division of Professional Licensing Services form 3 Verification of Other Professional Licensure/CertificationComplete this form if you hold, or have ever held, a license or certificate to practice any profession* in any jurisdiction *Profession is defined as professional titles licensed under New York State Education Law (see page 2 of the Address/Name Change form ).Applicant Instructions 1. Complete Section I. In item 4, enter your name exactly as it appears on your Application for Licensure ( form 1). Be sure to sign and date item 10. 2. Send the entire form to the appropriate licensing/certifying authority for completion of Section II.

Nurse Form 3, Page 1 of 2, Revised 5/17. Section II - Verification of Licensure/Certification (Please print or type) Instructions to the Licensing/Certifying Authority: Please complete items 1-4, sign and date the certification and return both pages of this

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