Nursing

Application Forms: Nurse Practitioner

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.

Note: All forms are in Adobe Acrobat Portable Document Format (PDF). To view or print these documents, you will need to have the free Acrobat Reader installed on your computer. Download times and print quality will depend on your connection speed and printer.

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All applicants must complete this form and submit it with the $80 certification fee directly to the Office of the Professions at the mailing address on Form 1. Make checks payable to the New York State Education Department. NOTE: Your cancelled check is your receipt.

You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all 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 certification application, we will send you an acknowledgement letter.

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.

For applicants who have completed a licensure qualifying program registered by the State Education Department or a program determined by the Department to be equivalent.

This form must be submitted directly to the Office of the Professions from the professional school you attended.

Section I: Complete this section of the form before sending it to your school.

Section II: The Registrar must complete this section and return the form directly to the Office of the Professions at the mailing address on the form.

For applicants who have completed a program other than a New York State registered, licensure qualifying program.

Section I: Complete this section of the form before sending it to the academic institution or professional association where you completed instruction in New York State and federal laws relating to prescriptions and record keeping.

Section II: The Registrar or appropriate official must complete this section and return the form directly to the Office of the Professions at the mailing address on the form.

For applicants who have completed a program other than a New York State registered, licensure qualifying program.

Section I: Complete this section of the form before sending it to the academic institution or professional association where you completed the required pharmacotherapeutic course.

Section II: The Registrar or appropriate official must complete this section and return the form directly to the Office of the Professions at the mailing address on the form.

For applicants using national certification route.

Section I: Complete this section of the form before sending it to the national certifying organization to verify your passing of the nurse practitioner certification examination.

Section II: The national certifying organization must complete this section and return the form directly to the Office of the Professions at the mailing address on the form.

For applicants following alternative certification requirements.

This form is required within 90 days after commencement of practice.

Section I: Complete this section of the form before sending it to the physician who supervised your experience within the specialty for which you are seeking certification.

Section II: The supervising physician must complete this section and return the form directly to the Office of the Professions at the mailing address at the end of the form.

For all applicants.

Section I: Complete this section of the form.

Section II: You and the collaborating physician with whom you have a practice agreement and practice protocol must complete this section and return the form to the Office of the Professions at the mailing address at the end of the form.