Public Librarian Replacement Certificate Application
DO NOT WRITE HERE Fee Paid _______________ Check # ________________ |
The
University of the State of New York |
Application for Replacement of Public Librarian's Professional Certificate
Name (Print or type)
__________________________________________________________________________________________
(Ms.)(Mr.)(Mrs.) First
Middle
Last
(Name under which you were originally certified)
Please carefully print or type in the
spaces provided below your name as you wish to see
it appear on the certificate.
First Name
Mailing Address
__________________________________________________________________________________________
Street City State Zip
__________________________________________________________________________________________
Home Phone Work Phone
________________________________________________
E-mail address
Number of Public Librarian's Professional Certificate Now Held (if known): __________________________
Date of Issue (if known) ___________________________
Reason for requesting replacement _______________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I hereby apply for replacement of the Certificate
described above and certify that the information given
in this application is true and correct.
__________________________________________________________________________________________
Date
Signature
of Applicant
Social Security Number (last
four digits)
X |
X |
X |
- |
X |
X |
- |
Please return this form to:
Public Librarian
Certification
The State Education Department
Division of Library Development
Cultural Education Center - Room 10B41
Albany, New York 12230
Check for $5 payable to the State Education Department must accompany application.