Get Endorsement Applicant Experience Record - Office Of The ... - Op Nysed

Filling out the Endorsement Applicant Experience Record is a crucial step for applicants seeking licensure in New York State by endorsement in the field of psychoanalysis. This guide provides clear and supportive instructions for each section of the form to ensure a smooth application process.

Follow the steps to complete your application accurately.

1. Click ‘Get Form’ button to obtain the Endorsement Applicant Experience Record and open it in your preferred document editor.
2. Begin by filling out Section I: Applicant Information. Enter your Social Security Number, leaving it blank if you do not have one. Provide your birth date, and ensure to print your name as it appears on your Application for Licensure (Form 1).
3. Continue with your mailing address, including all relevant lines, city, state, zip code, and country or province. Remember to promptly notify the Department of any changes to your address or name.
4. Fill in your daytime telephone number, including area code, and provide your email address clearly. This information is crucial for communications regarding your application.
5. If applicable, indicate whether you have ever changed your name by answering 'Yes' or 'No'. If 'Yes', print your former name(s) in the space provided.
6. List your licensed colleague(s) on page 2 who will verify your experience for licensure. Ensure each colleague has knowledge of your work in psychoanalysis for at least five years within the past ten years.
7. Complete the section with the assigned number, name, and address of each verifying colleague along with the corresponding dates of experience.
8. Read and complete the attestation statement, ensuring that all provided information is true, complete, and correct. Sign and date the form as required.
9. Finally, return the completed form directly to the New York State Education Department at the specified address. After filling out the form, you can save any changes, download a copy, print it out, or share it as needed.

Ensure your application is completed accurately and submit your documents online today.