License/Certification 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.

Note: All forms are in Adobe Portable Document Format (PDF). To view or print these documents, you will need to have the free Adobe Reader External Link Icon installed on your computer. Download times and print quality will depend on your connection speed and printer.
Form 1 - Application for Licensure/Certification ( PDF 26 KB)

Important Notice: A New York State professional license is valid for life unless it is revoked, annulled, or suspended by the Board of Regents. To practice in New York State your professional license must be registered. If your registration has lapsed and you need to reregister, do not submit a Form 1. Instead, contact our customer services unit to request a Delayed Registration Application by e-mailing: op4info@nysed.gov, or by calling 518-474-3817 Ext. 570. When e-mailing, be sure to include your profession, license number, address on record, new address (if changed), date of birth and the last 4 digits of your SSN.

All applicants for licensure/certification as licensed behavior analysts or certified behavior analyst assistants must complete this form and submit it with the appropriate fee ($300 for licensed behavior analyst and $225 for certified behavior analyst assistants) for licensure/certification and first registration 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. You must sign and date the affidavit on this form in the presence of a Notary Public.

Address/Name Change Form - Optional ( PDF 20 KB)
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 - ( PDF 17 KB)
Complete this form if you would like your education to be reviewed under the standard licensing provisions (Pathway Two). The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section of the form before sending it to the institution(s) where you completed your professional education. If you completed a program that was not registered by the New York State Education Department as licensure-qualifying at the time the degree requirements were met, be sure to request that institution to provide an official transcript or official marksheets, as well as course descriptions and/or syllabi for all courses, if available.
  • Section II: The Registrar must complete this section and return the form along with any other required documentation directly to the Office of the Professions at the mailing address at the end of the form.
Form 3 - Verification of Other Professional Licensure/Certification - ( PDF 17 KB)
Complete this form if you hold, or ever held, a license or certificate to practice any profession* in any jurisdiction. Note: DO NOT use this form to verify certification in Applied Behavior Analysis by a national certifying body.

This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before sending the entire form to the appropriate licensing/certifying authority. Be sure to sign and date item 7. A separate Form 3 must be submitted for all licenses/certificates you have ever held except those issued by the New York State Education Department.
  • Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

NOTE: A Form 3 is not required for licenses/certificates issued by the New York State Education Department.

*Profession is defined as professional titles licensed under New York State Education Law. (See page 2 of the Address/Name Change Form ( PDF 20 KB) for a list of those titles.)

Form 4 - Report of Professional Experience - (PDF 19 KB)

This form must be submitted directly by the qualified professional who provided supervision of the professional experience claimed by the applicant. Please see General Information for Completing Report of Professional Experience (HTML | PDF PDF) for further information. This form will not be accepted if submitted by the applicant.

  • Section I:Complete Section I in ink. In item 3, enter your name exactly as it appears on Your Application for Licensure/Certification (Form 1). Besure to sign and date item 7.
  • Section II: Make a copy for your records and forward this original form along with a copy of the Form 4Inf to your supervisor to complete Section II.The supervisor must send the form directly to the Office of the Professions at the address at the end of the form.

Note: Aseparate form 4 must be submitted for each setting you wish to claim towards the experience requirement.

Form 5 - Application for Limited Permit - ( PDF 18 KB)
  • Section I: Complete this section of the form before having your prospective supervisor complete Section II. Please be sure to sign and date item 9.
  • Section II: Your prospective supervisor must complete this section. You must meet all other requirements for licensure except the examination and experience requirements, in order to be eligible for a limited permit.

In addition to the Form 5 and $70 limited permit fee, you must submit the Application for Licensure/Certification (Form 1) and the appropriate fee for licensure/certification and first registration. The Department must approve your education before your application for a limited permit can be approved. Return the completed Form 5 to the Office of the Professions at the address at the end of the form.

For further information on permanent license/certification provisions, please see license/certification requirements.
 
Last Updated: June 17, 2016