Application for Evaluation of Eligibility for Public Librarian's Conditional Certificate
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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
Mailing Address
________________________________________________________________________________
Street
________________________________________________________________________________
City
State
Zip
(________)________________________________________________________________________
Telephone
________________________________________________
E-mail address
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____________ |