The University of the $tate of New York
Nurse Form 2F The $tate Education Departrnent
OSi*e of the Prafessions
Certification of Foreign Nursing Education Division of Professional Licensing $ervices
[Link]*[Link]
App lcsnt lngtructions
I
1 . Use this form ONLY lf your nurclng school le locabd outslde the Unltod Statos or its terrltorlec aN you were advlsed Stat
CGFtrlS did not obtain full documentation needed for e l{erv York State nurslng llcense revlew of your CGFI{$ Credenfials
Veriflcatlon Seruice for New Yor* Sta& Appllcatlon or you are not utillzlng the rsrvlces of GGFNS.
2. Complete Section l. ln item 4, enter your name exactly as it appears on your Application for Licenrure (Fonn 1). Be sure to eign and
date item 8.
3. Have the professional sc-hool you attended complete the appropriate parts of Section ll. Be sure to include any fee required by the
school. The school of nursing mu$t retum the entirc form in a eealed oficial schml envelope along with an offcial hansolpt direcfly to
the Ofrce of the Professions at the addess at the end of this form. lf the transoipt is not in English, a qualified translation is also
rcqulred. For information on what constitutes a qualified Sanslation, eee our website [Link]/[Link]#verif. Thir
form and trefficrlpt wlll not be accepted lf submitted by the appllcant or any pemon or agincy othor tlan fire proper cchool
authorlty.
I.
1 . Check what you are aplying for fl negistared Professbnal Nurse I t-icenseO Pnac*ical Nurse
2. $ocial Security Number 3. tsirth Date Month 1 0 Day ? 1 Year 1 g I I
(Leow thls blank tl W do td harc a U.S. $oc&l $eari{y tYum0en)
4. Prinl Your Name F:xacdy As lt AWrs On Your Appticaffon for Lh8nsuro (Fqnr 1).
Laet B A I s
First $ u Z A I N E
Middle M E R c A D o
5. Mailing Addrcss (You must notiff the Departrnent pmmptly of any address or name changes).
Line 1 2 2 I s 5 R A T l{ G A R A V E r*lu E
Line t u N I T 2 2
Line S
City w I N N I P E G
$tate M B ZIP Code R 3 L 1 Y g
Cour*ryJ
Pnovine c A N A D A
6. Print your name a$ it appears on your degrce or diploma SUZAINE C- MERCADO
7, Nursing school attended ST. JO$EPH COLLEGE
Address PIARIDEL $T, $AN ROQUE, CAVITE SITY,4100 SAVITE, pHlLlpPlNES
Sates *f attendanm frum ?L *1S 05 tCI 03 26 09
-rfxr Tery E rno-* w yr"
Date degleeldiploma ulas avuarded 03 26 09
mA* @ yr.
NandTi0e of the Degree/tXploma [Link] b you BACHELOR OF SCIENCE lN NURSING
8. I request and gtua my permission to lhe schod tisted in item 7 above to complete Section ll of this fonn and mail it to tho New york $aG
Education Department at the address at the and of this form, and to rcleass any other inbrmation requested by the State Education
Departrnent in connection with my application tor licensure.
L+ }c*ober 2027
Date
Form 2F, Page 1 of 2, Revised 3/18
\
Ssrtirln - Certificatian of, I Educatiorr
l
Itr
lnstructions to the School of Nursing: Complete Section ll to documenl the applicant's education. Sign and date the certification and return both pages of this
form along with an of{icial transcript in a sealed official school envelope directly to the Office of the Pmfessions at the address below, Do not return this form to
the applicant. This form and transcript will rot be accepted if returned by lhe applicant or any person or agency other than the proper school authorlty.
1. Name *f the applicant
{s*e Secfi*n /, rf#m #,i
2. Nunslng schoul ftarrre
F*rnier sch**at ftar*e
Address
{Sir:*e{i
ilrftri [Link]/Fr$vrr?##J {Xitr Ccd*j {Ccunffi
3. Nursing Prngram lnfamnatiry":
Length *f the Frogrant L*nguase sf instru*ti*n used
Date of admissicn
-mo.
Date of completion
Tay yr. mo. Tay y..
Years of education required for admission Date of graduation
nno. Tay y'1
Title of degree or diploma awarded Date degree or diploma was awarded
st*- Eay y,
Type of program l-l Baccalaureate f O;ptoma [! Associate f, Ottrer
This program was approved as preparing for licensed practice as a I general or professional nurse or as an f auxiliary/second level nurse
by:
Name of the Registration Authority who approved this prograrn
tnitial dete the pn:grarrx w*s appr*ved hy the Registr*ti** Auth*rttis
fT]*. E!, yr
if N*Y fipprovecl fcr generei r:ursing praotice, plee:*q# *xpl*ir':
Note: An official transcript or mad<sheets is issued by the schcol showing completed courses by year and grades and bears original school
official's signature{si and an original schoot seal{s}. lt must be received directly frorn the school along with this form in a sealed official sct}ool
envelope.
I hereby certify tha: to the best of rny knowledge and belief the information ln Sectior ll is a true statemeftt of the record of the professional
education of the individual named on lhis form.
Signature t>f ftegistr*r *at*
Prlnt Narn*
Ir-rstituti*n
Address
T*ieph*ne Fax
Inraii
Retum Directly to: New York State Edueation Oepartment, Offrce of the Professions, Division of Professionat Licensing Services, Nurse tlnit,
89 Washington Avenue, Albany. NY 12234-1000, U.S.A..
$ct*hsr ?7,2*23
Trl Wh*rn It Mn}, Ccn*#rn.
[, the undersigned, hereby authorize my aunt Ms. Yeronica M.
Toledo to act on my behalf in requesting and obtaining my
oflicial Transcript of Records (TOR) & Summary of Related
Learning Experience (RLE).
I also attached in this request is the Nurse Form 3F Verification
eif Foreign Professionals. I ask your good office to camplete,
sign & mail this fbrm, including my Transcript of Record &
Sunrmary of Related Learning Experience, to the New York
State Education Department (NYSED). Complete instructions
are on the top af Page 2.
I alsoattached photocopies of my identifications & necessary
informaticn with this letter.
Ti:ank y*u t*t yt:ur c#nsid*ratic>tt affid a$$istfrn#*,
R*spef,tfully Y*urs-
ffre"-l
Suxaine Msrcadqs ffi*is
