Follow the steps to complete your attestation form effectively.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editor.
2. In Section I, provide your applicant information. Fill in your social security number if you have one, and include your birth date. Next, print your full name, including your last, first, and middle names.
3. Indicate your licensee business address, phone number, and email. Choose whether this information relates to your home or business. Note that this data will become public information.
4. Fill in your mailing address. Indicate whether it is your home address or business address. Remember to notify the Department within 30 days if any changes occur.
5. If you have a New York State DMV ID number, include it here. Leave this field blank if you do not have one.
6. Provide your daytime telephone number and email address, clearly identifying whether it is associated with your home or business.
7. In Section II, enter the name of the Clinical Laboratory Director, their Certificate of Qualification Identification Number, and the authorized category of practice.
8. Include the name and address of the Clinical Laboratory providing the training program. If the responsible entity differs, provide that entity's details as well.
9. Both you and the Clinical Laboratory Director must initial next to each content area to confirm agreement on what will be included in the training program.
10. Ensure that these initial areas cover all necessary knowledge and skills outlined in the guidelines.
11. In the description of the program section, provide an overview of the training program’s structure, timing (full-time or part-time), and supervision details of involved persons.
12. Clearly state the designated title of the trainee, such as intern, trainee, fellow, or student.
13. Both you and the Clinical Laboratory Director need to sign and date the attestation section of the form, affirming you understand the content requirements.
14. Once all sections are completed, ensure to save your changes, then proceed to download, print, or share the filled form as necessary.

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