Limited License Application Forms
Clinical Laboratory Technologist & Certified Histological 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.- Complete Application Packet
All forms and instructions in a single PDF file - Clinical Laboratory Technologist & Certified Histological Technician Limited License Application Packet (
120 KB)
- Form 1LL - Application
for a Limited License Licensure ( 27
KB)
- All applicants for licensure must complete this
form and submit it with the appropriate fee for licensure and first
registration 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 2A -
Certification of Training/Experience (
18
KB)
- This form must be submitted directly by the Clinical
Laboratory Director/Principal Researcher of the clinical
or research laboratory where you received your training/experience.
The Office of the Professions will not accept this form
if submitted by the applicant.
- Section I: Complete this section before sending both pages to the Clinical Laboratory Director/Principal Researcher of the clinical or research laboratory where you received your training/experience. Be sure to sign and date item 6.
- Section II: The Clinical Laboratory Director/Principal Researcher
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.
- Form 3 -
Verification of Other Professional Licensure/Certification ( 18
KB)
- Complete this form if you hold, or have 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.
NOTE: 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 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.
