NYS Podiatry Application Forms

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All applicants for licensure must complete this form and submit it with the licensure and registration fee 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. NOTE: 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.

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.

Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 8.

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

Use this form if you are or ever have been licensed in another U.S. jurisdiction.

Section I: Complete this section and forward this form to the licensing authority of the jurisdiction in which you are licensed. Ask the licensing authority to complete Section II and submit the completed form directly to the Office of the Professions at the address at the end of the form.

Section II: An official from the licensing authority must complete this section and return the form directly to the Office of the Professions at the address at the end of the form.

Note: A separate Form 3 must be received from every state, province or country in which you are or ever have been licensed.

Section I: Complete this section before forwarding it to the Director of Podiatric Medical Education at each hospital in which you completed approved post-graduate podiatric residency training.

Section II: The Director of Podiatric Medical Education must complete this section and return the form directly to the Department. Certification of approved postgraduate podiatric residency programs will be accepted only if they are signed no more than one month prior to the completion date of the residency training program and submitted to the Department directly from the Director of Podiatric Medical Education.

Form 5A or 5B - Application for a Limited Permit

This application form is only for applicants requesting a limited permit who also seek licensure in New York State.

If you have already submitted your application and fee for licensure and requested that the Certification of Professional Education (Form 2) be sent to the Department, you need only submit Form 5A and the appropriate fee for the limited permit. If you are not seeking licensure but still wish to apply for a Limited Permit, you must complete Form 5B.

Section I: Complete all parts of this section before forwarding it to your prospective employer. Be sure to sign and date item 8.

Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.

This application form is only for applicants requesting a limited permit who do not seek licensure in New York State. If you are seeking licensure and wish to apply for a Limited Permit, you must complete Form 5A.

In addition to Form 5B, the Department must receive the Certification of Professional Education (Form 2), the appropriate limited permit fee and proof that you have completed the required training in the identification and reporting of child abuse.

Section I: Complete all parts of this section before forwarding it to your prospective employer and be sure to have your signature notarized in item 23.

Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.

Note: You must complete the required coursework or training in the identification and reporting of child abuse and submit a certificate of completion from an approved provider or an exemption form.

Form 5C or 5D - Application for a Limited Residency Permit

This application form is only for applicants requesting a limited residency permit who also seek licensure in New York State. If you are not applying for licensure or are already licensed in New York State, you must use Form 5D to apply for a limited residency permit.

Section I: Complete all parts of this section before forwarding it to your prospective employer and be sure to have your signature notarized in item 15.

Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.

This application form is only for applicants requesting a limited residency permit who are not seeking licensure in New York State. If you are applying for licensure, you must use Form 5C to apply for a limited residency permit.

Section I: Complete all parts of this section before forwarding it to your prospective employer and be sure to have your signature notarized in item 24.

Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.

This form is not for all applicants. Use this form only if you are applying for an exemption to the requirement to complete training or coursework in the identification of child abuse and maltreatment because the nature of your practice excludes contact with children.

Podiatry

License Application Forms

Form 5A or 5B - Application for a Limited Permit

Form 5C or 5D - Application for a Limited Residency Permit