CERTIFICATION OF COMPLETION
THE NEW YORK STATE EDUCATION DEPARTMENT
CERTIFICATION OF COMPLETION
PART A
TRAINEE INFORMATION
1.
Trainee must complete ALL items in Part A. Return to provider for completion of Part B,
"Certification b A roved Provider". An incom lete form will not be recessed.
2.
The provider will return the Certification form, with Part B completed, to the trainee. It is the
trainee's responsibility to submit the original copy of this Certification form to the New York
State Education Department at the appropriate time. It should be submitted along with other
relevant forms when the trainee applies for certification. Mail to: NYS Education Department,
Office of Teachin Initiatives, 89 Wash in ton Ave., Alban , NY 12234
Last Name:
First Name:
Middle
Name/Initial:
2.
Print our address:
Care of:
Street:
Zip Code:
3.
Date of Birth
4.
Last4 of the Social Securi
Trainee's Si nature:
PART B
Year:
Month
Number:
Date:
CERTIFICATION BY APPROVED TRAINING PROVIDER
\IOIDED
;rhis section must be completed by the
provider
................
................
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