License Application Forms

Clinical Laboratory Technologist & Technician

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 ( PDF 27 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 the Registration and Fees Unit to request a Delayed Registration Application by e-mailing: OPREGFEE@nysed.gov, or by calling 518-474-3817 Ext. 410.  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 must complete this form and submit it with the licensure and first registration fee ($371 for clinical laboratory technologists and $263 for certified clinical laboratory technicians) directly to the Office of the Professions at the 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.

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 18 KB)

This form must be submitted directly by the educational institution(s) you attended. 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 your school. Be sure to sign and date item 9.
  • Section II: The Registrar must complete this section and return both pages of the form in a school envelope with requested documents directly to the Office of the Professions at the address at the end of the form.

Form 3 - Verification of Other Professional Licensure/Certification ( PDF 18 KB)

Complete this form if you hold, or ever held, a license or certificate to practice any profession* in any jurisdiction.

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 licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
  • 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.

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

NOTE: This form is to verify other professional licensure only and should NOT be used to verify New York City Certification of Qualification or any affiliations with professional associations or organizations. A Form 3 is not required for licenses/certificates issued by the New York State Education Department.

Form 4C - Certification of Experience and Competence (For Applicants using Grandparenting Methods 1A and 6A Only. Applications using these methods will only be accepted if submitted by September 1, 2013.) ( PDF 20 KB)
This form must be submitted directly by the Clinical Laboratory Director(s) who supervised your experience. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before giving the entire form to the Clinical Laboratory Director(s) who supervised your experience. Be sure to sign and date item 6.
  • Section II: The Clinical Laboratory Director(s) who supervised your experience must complete this section 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 separate Form 4C must be submitted for each supervised experience.

Form 5 - Application for Limited Permit ( PDF 19 KB)
  • Section I: If you are applying for a limited permit, complete this section before having your prospective employer complete Section II. Be sure to sign and date item 9.
  • Section II: Have the Director of the clinical laboratory who will be your general supervisor complete Section II.

Return the completed form with the $50 fee to the Office of the Professions at the address at the end of the form.

You may apply for a limited permit by submitting the Application for Limited Permit (Form 5) and limited permit fee of $50 at the same time or any time after you submit your Application for Licensure (Form 1), licensure and first registration fee ($371 for clinical laboratory technologists, $263 for certified clinical laboratory technicians), and evidence of satisfactory education.

Last Updated: April 7, 2014