The University of the State of New York

Application for Replacement of a License The State Education Department

Office of the Professions
(or Certificate) Parchment Division of Professional Licensing Services
www.op.nysed.gov

Your parchment is a unique, diploma-like document issued only once, when you are initially licensed. It is permanently valid unless revoked,
annulled, or suspended by the Board of Regents. Do not confuse it with your registration certificate, which you renew periodically.
Instructions: Complete this form, be sure to sign and date the affidavit before submitting this form to the Office of the Professions at address
at the end of the form. If the parchment is damaged or you are requesting a replacement for a new name, you must return your old
parchment with this application.

Name GLENN DAVE VILLAREAL MARCELO Date 01 06 23

mo. day yr.

Address 16TH STREET, BUILDING 40 - AL MAMOORAH, FLAT 214, AL HAMRIYA, BUR DUBAI, DUBAI, UNITED ARAB EMIRATES

Profession REGISTERED PROFESSIONAL NURSING

New York State License Number 8 4 4 3 1 5 Date of Licensure 05 27 22

mo. day yr.
Social Security Number

Birth Date Month 0 9 Day 1 0 Year 1 9 9 2

Daytime Telephone Number +971543213479 Contact Email GLENNMARCELO92@GMAIL.COM

Print name exactly as it appears on your original parchment GLENN DAVE VILLAREAL MARCELO

Indicate reason for replacement of your parchment. If the parchment is damaged or you are requesting a replacement for a new
name, you must return your old parchment with this application.
Lost Stolen* Damaged* New Name 4 Other*

*Explain Fully

PARCHMENT NEVER RECEIVED

Note: Should you recover a lost parchment, it should be returned to this office immediately at the address at the end of the form.

Affidavit

Under penalties of perjury, I declare and affirm that the statements made in the foregoing application are true, complete and correct.

01-06-2023
Licensee Signature Date

Mail this form to: New York State Education Department, Office of the Professions, Records and Archives Unit, 89 Washington Ave,
Albany, NY 12234-1000.

For Department Use Only

Initials Date

Parchment Returned? Yes No

Date

Application for Replacement of a License (or Certificate) Parchment Form, Revised 10/17