The University of the State of New York Clinical Laboratory
The State Education Department
Office of the Professions Technologist/Technician Form 2
Division of Professional Licensing Services
[Link]
Certification of Professional Education
Applicant Instructions
1. Complete Section I and sign and date item 9.
2. Send the entire Form 2 to the institution(s) you attended, including any fee required by the institution, and have the registrar complete
Section II and return all pages in an official school envelope directly to the Office of the Professions at the address at the end of this form.
Form 2 will not be accepted if submitted by the applicant or if it is received in a personal envelope.
3. An official transcript or marksheets and syllabi are required if you completed a program that is not registered by the Department as
licensure qualifying at the time of your graduation or accredited by an organization acceptable to the Department.
Check what you are applying for (check one): Clinical Laboratory Technologist Certified Clinical Laboratory Technician
Section I: Applicant Information
1. Social Security Number 2. Birth Date Month Day Year
(Leave this blank if you do not have a U.S. Social Security Number)
3. Print Name Last
First
5. Telephone/Email Address
Middle Daytime Phone
Home or Business
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
Area Code Phone
4. Mailing Address Home or Business
(You must notify the Department within 30 days of any address or name changes) Email Address (please print clearly)
Home or Business
Line 1
Line 2
Line 3
6. New York State DMV ID Number
City (Driver or Non-Driver ID)
State ZIP Code
(Leave this blank if you do not have a
Country/ New York State DMV ID Number)
Province
7. Name as it appears on your Degree/Diploma/Advanced Certificate
8. Name of institution attended
Address of institution
Title of Degree/Diploma/Advanced Certificate awarded (in original language)
Date Degree/Diploma/Advanced Certificate awarded Not yet awarded
mo. yr.
9. I request and give my permission to the institution listed in item 8 above to complete Section II of this form and mail it to the Office of the
Professions at the address at the end of this form, and to release any other information requested by the State Education Department in
connection with my application.
Signature Date
Clinical Laboratory Technologist/Technician Form 2, Page 1 of 2, Revised 10/20
Section II: Certification of Professional Education
Instructions to the Registrar: Complete Part A or Part B, and complete and sign the Certification. Return the entire form along with any required
documentation in an official school envelope directly to the Office of the Professions at the address at the end of this form. Form 2 will not be accepted if
submitted by the applicant. For programs not registered by the Department, an official transcript or marksheet and syllabus must be attached.
Name of the applicant
(see Section I, item 7)
Part A - Program Registered by the New York State Education Department (NYSED): To be completed only by those schools whose
clinical laboratory program was, at the time the applicant's degree was (or will be) awarded, registered by the NYSED.
It is certified that the applicant:
completed the program on and was awarded the degree/diploma/advanced certificate of
mo. day yr.
on the date of ; Or
(Title of degree/diploma/advanced certificate) mo. day yr.
on this institution determined that the applicant met all requirements for the degree/diploma/advanced certificate
mo. day yr.
and the institution has agreed to award the degree/diploma/advanced certificate of
(Title of degree/diploma/advanced certificate)
Part B - All other programs. An official transcript or marksheet giving courses completed by year and grades and a syllabus of the
course of studies completed must be attached.
1. Does your program include course content on infection control and universal precautions? Yes No
2. Does your program include course content on maintenance of equipment and records (technologists only)? Yes No
3. Does your program include course content in ethics, as it relates to health care? Yes No
If yes, list applicable courses that contain ethics content
4. Date of applicant's entrance, and either the applicant's date of completion of studies or withdrawal from the school
Entrance Date Completion Date Withdrawal Date
mo. day yr. mo. day yr. mo. day yr.
5. Degree/diploma/advanced certificate awarded
6. Date degree/diploma/advanced certificate awarded
mo. day yr.
Name of the accrediting body or official organization that recognizes this program
Date of Accreditation
mo. day yr.
Address of the accrediting body or official organization that recognizes this program
Certification - To be completed by the Registrar
I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the educational record of the
individual named on this form.
Signature of Registrar Date
Print Name
Title or official position
Institution
Seal
Address
Telephone Fax Email
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Clinical
Laboratory Technology Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Clinical Laboratory Technologist/Technician Form 2, Page 2 of 2, Revised 10/20
