Application for Public Librarian's Professional Certificate

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Name (Print or type)

(Ms.)(Mr.)(Mrs.)__________________________________________________________________
First Middle Last

Clearly print or type your name in the space provided below as you wish it to appear on the certificate.

First Name

Middle Name (or initial)

Last Name

Mailing Address
_____________________________________________________________________________________
          Street                                                        City                               State                       Zip Code

Home Phone ______________________________
Work Phone ________________________________

E-mail address ______________________________________________

Having met all requirements, I hereby apply for a public librarian’s professional certificate. I understand that, in order to maintain active certification, I must complete 60 hours of professional development every five-year period, such period to be defined from the initial certificate date.

EDUCATION

Degree-Granting Institution*
*Verification of MLS, in the form of an official transcript from the degree-granting institution, must be provided by applicant unless such verification has been submitted by the degree-granting institution.

Check one:
    ___ Transcript enclosed ___ Transcript to be forwarded by degree-granting institution

__________________________________________________________________________________________
Name of Degree-Granting Institution       City/State __________________________________________________________________________________________
Degree Granted

Last Four Digits of Social Security Number: X X X - X X - ___ ___ ___ ___

____________________________________________________________________________________________________
          Signature of Applicant                                                                                         Date
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____________

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

Last Updated: January 30, 2013 --asm; for questions or comments, contact us -- asm