Application for Evaluation of Eligibility for Public Librarian's
CONDITIONAL CERTIFICATE

This document also available in MS Word and .PDF formats

Name (Print or type)
__________________________________________________________________________________________
      (Ms.)(Mr.)(Mrs.)                               First                               Middle                               Last

Print or type in the spaces provided below your name as you wish to see it appear on the certificate.
First Name
                                       
Middle Name (or initial)
                                       
Last Name
                                       

Mailing Address

________________________________________________________________________________
          Street


________________________________________________________________________________
          City                                                    State                               Zip


(________)________________________________________________________________________
          Telephone

________________________________________________
          E-mail address

COMPLETE STATEMENT OF EDUCATION
 

Name of School and City

Dates Attended

Certificate or Degree Awarded

Date

Secondary School        
College or University        
Library School        
Other Schools        

Copies of documents verifying college level study must be submitted including a transcript (list of courses) and diploma of all postsecondary study. If you have had work experience, list on the back each library, your position and the dates you worked. Indicate any work experience using English if that is not your native language.

X X X - X X - __________
          Last Four Digits of Social Security Number

__________________________________________________________________________________________
          Signature of Applicant                                                                                                                   Date

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.

DO NOT WRITE HERE

Fee Paid _______________

Check # ________________

 

DO NOT WRITE HERE

Cert.No._______________

Date Issued____________

Back to Public Librarian Certification page | Go to Library Development Home Page