Student Attestation Form/Statement

First Name

Last Name

Email Address

Student ID Number (Ex. 805000000)

Birthdate

Major

Date

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 the following statements:

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