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This form will not be reviewed if submitted after the experience has been completed or if the experience will be outside of New York State.

  • Section I: Complete this section and send the entire form and a copy of Appendix A to your proposed supervisor. Be sure to sign and date item 9.
  • Section II: The proposed supervisor must complete this section.

Return the completed form with the $10 fee to the Office of the Professions at the mailing address at the end of the form.