Medical Physics
License Application Forms
Instructions for completing and submitting the forms required for licensure appear below. You may also need to submit additional information (for example, examination scores). Please refer to the license requirements link on the left for complete information regarding all requirements you must meet.
Form 1 - Application for Licensure and First Registration (mp1.pdf; 37K; 4 pages)
All applicants for licensure must complete this form and submit it with the $450 licensure and registration fee (and an additional fee of $325 for each additional specialty) directly to the Office of the Professions at the mailing address at the end of Form 1. Make checks payable to the New York State Education Department. Your cancelled check is your receipt.
You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review. Your signature on Form 1 must be notarized by a notary public. Upon receipt of your completed application, we will send you an acknowledgement letter.
Address/Name Change Form - Optional (anchange.pdf; 41K; 2 pages)
You are required to notify us within 30 days of any name or address changes. Please read the instructions and complete the appropriate sections of this form.
Form 2 - Certification of Professional Education (mp2.pdf; 23K; 2 pages)
This form must be submitted directly by the educational institution you attended.
Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 8. Be sure to include any fee required by the school. A separate Form 2 should be submitted for each educational program attended that will demonstrate satisfaction of the professional education requirement.
Section II: The Registrar or appropriate school official must complete this section and return the form in a school envelope directly to the Office of the Professions at the mailing address at the end of the form.
- Graduates of Master's and Doctoral programs from accredited United States colleges or universities must send this form to each college/university where you attended a graduate level program and request that each school complete the appropriate parts of Section II of this form and return it directly to the Office of the Professions with an official transcript.
- Graduates of Master's and Doctoral programs from colleges or universities located outside the United States and not accredited by a U.S. accreditation body must send this form to every college/university attended and request each school to complete the appropriate parts of Section II of this form and return it directly to the Office of the Professions with an official transcript.
Form 4 - Personal Affidavit of Professional Experience (mp4.pdf; 20K; 2 pages)
Complete this form and send it to the address at the end of the form. Be sure to sign and date item 6 and list all professional medical physicist work experience chronologically, beginning with your first employer to the present. Provide the name and address of each employer and the specialty area you practiced with each employer. Attach additional sheets if needed.
You should transcribe the professional experience information, including a comprehensive description of your professional experience, from the Form 4 to an individual Form 4A for each endorser you list (see Form 4A Instructions HTML | PDF for more information.)
Form 4A - Verification of Professional Experience (mp4a.pdf; 23K; 2 pages)
Instructions for Completing Verification of Professional Experience HTML | PDF (mp4ainst.pdf; 22K; 1 page)
This form must be sent directly by the endorser.
Section I: Complete this section and forward the form, along with a copy of the instructions, to the individual endorser who will attest to your practice of medical physics. Be sure to sign and date the attestation.
Section II: Have your endorser complete this section, sign and date the attestation and send the form directly to the Office of the Professions to the address at the end of the form. This form will not be accepted if submitted by the applicant.
Form 5 - Application for Limted Permit (mp5.pdf; 45K; 2 pages)
Section I: Complete this section before having your supervisor complete Section II. Be sure to sign and date item 18.
Section II: Have your supervisor complete Section II and return the completed form with the $60 fee to the Office of the Professions at the mailing address on the bottom of the form.
