Student Attestation Form/Statement

First Name

Last Name

Email Address

Student ID Number (Ex. 805000000)

Birthdate

Major

Date

Professional Licensure or Certification

Many professions and certifications are governed by state or territorial regulations. These regulations often dictate specific educational requirements for licensure or certification. For this reason, some of SUNY Canton programs or courses that lead to professional licensure and New York State certification may not meet the educational requirements of all states and territories. The attestation process ensures that students engage in the decision-making process with full awareness and consent.

I am interested in enrolling in a professional licensure or certification program at SUNY Canton. I have been informed that the licensure program at SUNY Canton is designed to meet the requirements for licensure in New York State.

Please initial each of the following statements with your initials:

I understand that if my current permanent (home) address is outside of New York State, I am prohibited by federal rule from being admitted into this Certification/Licensure program unless I submit this attestation.

I understand that if my current permanent (home) address is in New York State, I will not be prohibited from enrolling without this attestation but realize if my address changes while enrolled, it will become mandatory.

I confirm I have reviewed the general licensure disclosures provided by SUNY Canton that can be found at this webpage https://www.canton.edu/hea/licensure/. I understand that SUNY Canton is committed to working with me to determine my options if I choose to seek employment outside of New York State.

I acknowledge that I should contact any state in which I may be interested in becoming licensed upon graduation to ensure I fully understand my employment options in that state or country. The most reliable information comes directly from the applicable state licensure board or agency/entity.

I hereby attest and confirm that I plan to enroll in a licensure program that is designed and approved for the state of New York. If my current or future plans take me out of NYS, I understand that I must contact the applicable licensure board for my new location.

I knowingly and voluntarily submit this attestation.

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Student Attestation Form/Statement