Student Loan Disclosure Form - Office of the Professions - New York ...
Student Loan Disclosure Form - Office of the Professions - New York ...
Student Loan Disclosure Form - Office of the Professions - New York ...
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<strong>Student</strong> <strong>Loan</strong> <strong>Disclosure</strong><br />
<strong>Form</strong> 1SL<br />
The University <strong>of</strong> <strong>the</strong> State <strong>of</strong> <strong>New</strong> <strong>York</strong><br />
THE STATE EDUCATION DEPARTMENT<br />
<strong>Office</strong> <strong>of</strong> <strong>the</strong> Pr<strong>of</strong>essions<br />
Division <strong>of</strong> Pr<strong>of</strong>essional Licensing Services<br />
www.op.nysed.gov<br />
ALL APPLICANTS ARE REQUIRED TO COMPLETE THIS FORM<br />
Instructions<br />
The State Education Department is required* to ask <strong>the</strong> questions below about any student loans made or guaranteed by <strong>the</strong> <strong>New</strong> <strong>York</strong> State<br />
Higher Education Services Corporation, and to forward any “yes” responses to <strong>the</strong> <strong>New</strong> <strong>York</strong> State Higher Education Services Corporation. Your<br />
license application is not complete until this information has been received.<br />
Complete items 1-7. Be sure to sign and date item 8. Return this form to <strong>the</strong> <strong>Office</strong> <strong>of</strong> <strong>the</strong> Pr<strong>of</strong>essions at <strong>the</strong> address below.<br />
* <strong>New</strong> <strong>York</strong> State Education Law, Section 6501-a<br />
1<br />
Social Security Number<br />
(Leave this blank if you do not have a U.S. Social Security Number)<br />
2<br />
Birth Date<br />
Month Day Year<br />
3 Pr<strong>of</strong>ession:<br />
(Choose from <strong>the</strong> pr<strong>of</strong>essions listed on page 2 <strong>of</strong> this form)<br />
4<br />
Print Your Name Exactly As It Appears On Your Application for Licensure (<strong>Form</strong> 1)<br />
Last<br />
First<br />
Middle<br />
5 Mailing Address (You must notify <strong>the</strong> Department promptly <strong>of</strong> any address or name changes.)<br />
Line 1<br />
Line 2<br />
Line 3<br />
City<br />
State<br />
Zip Code<br />
Country/<br />
Province<br />
6<br />
Do you have any outstanding loans made or guaranteed by <strong>the</strong> <strong>New</strong> <strong>York</strong> State Higher Education Services Corporation? Yes<br />
No<br />
7<br />
If you have such a loan(s), is any part in default? Yes<br />
No<br />
8<br />
Under penalty <strong>of</strong> perjury, I declare and affirm that <strong>the</strong> above information is true, complete, and correct.<br />
_______________________________________________________________________________________<br />
Signature<br />
______________________________<br />
Date<br />
Return to:<br />
<strong>New</strong> <strong>York</strong> State Education Department, <strong>Office</strong> <strong>of</strong> <strong>the</strong> Pr<strong>of</strong>essions, Division <strong>of</strong> Pr<strong>of</strong>essional Licensing Services,<br />
(insert name <strong>of</strong> pr<strong>of</strong>ession from list on page 2) Unit, 89 Washington Avenue, Albany, NY 12234-1000.<br />
<strong>Form</strong> 1SL, Page 1 <strong>of</strong> 2, (Rev. 11/06)
Pr<strong>of</strong>essional Titles Licensed Under Education Law<br />
Acupuncturist<br />
Architect<br />
Athletic Trainer<br />
Audiologist<br />
Certified Clinical Laboratory Technician<br />
Certified Public Accountant<br />
Certified Shorthand Reporter<br />
Chiropractor<br />
Clinical Laboratory Technologist<br />
Creative Arts Therapist<br />
Cytotechnologist<br />
Dental Assistant<br />
Dental Hygienist<br />
Dentist<br />
Dietician/Nutritionist<br />
Interior Designer<br />
Landscape Architect<br />
Land Surveyor<br />
Licensed Clinical Social Worker<br />
Licensed Master Social Worker<br />
Licensed Practical Nurse<br />
Marriage and Family Therapist<br />
Massage Therapist<br />
Medical Physicist<br />
Mental Health Counselor<br />
Midwife<br />
Nurse Practitioner<br />
Occupational Therapist<br />
Occupational Therapy Assistant<br />
Ophthalmic Dispenser<br />
Optometrist<br />
Pharmacist<br />
Physical Therapist<br />
Physical Therapist Assistant<br />
Physician<br />
Podiatrist<br />
Pr<strong>of</strong>essional Engineer<br />
Psychoanalyst<br />
Psychologist<br />
Public Accountant<br />
Registered Physician Assistant<br />
Registered Pr<strong>of</strong>essional Nurse<br />
Registered Specialist Assistant<br />
Respiratory Therapist<br />
Respiratory Therapy Technician<br />
Speech-Language Pathologist<br />
Veterinarian<br />
Veterinary Technician<br />
<strong>Form</strong> 1SL, Page 2 <strong>of</strong> 2, (Rev. 11/06)
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