| New York State Library |
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
________________________________________________
E-mail address
Having met all requirements, I hereby make application for public librarian's professional certificate.
*Verification of MLS must be provided by applicant unless such verification has been submitted by library school.
EDUCATION
Graduate Library School*
__________________________________________________________________________________________
Name and City
Degree\Month\Year
X X X - X X - __________
Last Four Digits of Social Security Number
__________________________________________________________________________________________
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