Application for Public Librarian's Professional Certificate
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
Home Phone ______________________________ Work
Phone
________________________________
E-mail address ______________________________________________
Having met all requirements, I hereby make application for public librarian's professional certificate.
EDUCATION
Graduate Library School*
__________________________________________________________________________________________
Name and City
Degree\Month\Year
*Verification of MLS must be provided by applicant unless such verification has been submitted by library school.
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
Back to Public Librarian Certification page
For questions or comments contact Maria Hazapis or Dan Knickerbocker