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DO NOT WRITE HERE Fee Paid _______________ Check # ________________ |
The University of the State of New York |
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
________________________________________________
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)
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X |
X |
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X |
X |
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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.