The University of the State of New York
The State Education Department
Directions: Complete items 1-4. Be sure to sign and date the attestation below. Your signature on this form must be notarized by a Notary Public.
1. Name: __________________________________________________________________________
2. Address: ________________________________________________________________________
________________________________________________________________________
3. Profession: _____________________________________________________________________
4. New York State License Number: ___________________________________________________
Attestation
I hereby attest under penalty of perjury that I am not a United States citizen and I further attest that, as of this date, I do not live and am not practicing my profession in the United States. Further, I attest that if I should receive permission from the United States Immigration and Naturalization Service to enter the United States and practice my profession in New York State, I will immediately inform the New York
State Education Department in writing and include my profession, license number, and proof of immigration status at the time.
Signature: _____________________________________________________________ Date: _______ / _______ / _______ mo. day yr.
Print Name: ____________________________________________________________
Sworn to before me this _____________________ day of _________________, ________________ month year
Notary Public signature ________________________________________________________________________________
Notary ID number _______________________________
Expiration date __________ / __________ / __________
Month Day Year