License Application Forms
Clinical Laboratory Technologist & Technician
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
installed
on your computer. Download times and print quality will depend on your
connection speed and printer.- Form 1 - Application
for Licensure (
27 KB) - 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 ( 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 ( 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 ( 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 (
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.) ( 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 ( 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.
