This form must be NOTARIZED and MAILED to Jamestown Community College in order for you to receive your certificate.

MAIL TO:

Jamestown Community College Office of Continuing Education P.O. Box 20 525 Falconer Street Jamestown, NY 14702-0020

This affidavit/affirmation and application for certification will serve as verification as to the identity of the student enrolled in the web-based designed course Barrier Precautions and Infection Control. This affirmation is to be used to identify the student, in question, enrollment into Jamestown Community College's mandated course for health care professionals, as required by the State Education Department, Post Licensure Education Unit of the State of New York. Students enrolled into this class will be required to submit this completed form as part of the course requirement.

(Name) ______________________________does hereby swear/affirm that

she/he resides at (Street/P.O. Box) _____________________________________

in the (City/Village/Town) _____________________________________________

county of (County) ______________________________ state of _______________

(Name) ________________________________ has affirmed to me through picture ID, driver's license or passport, and has sworn to me that they are the individual enrolled in the Barrier Precaution and Infection Control on-line course, and is completing the necessary coursework.

  Sworn to or affirmed before me this ___________ day of ___________ 20____

  Stamp of notary public: __________________________________     Date __________

  Signature of notary public ________________________________