Limited License Application Forms

Clinical Laboratory Technologist & Certified Histological 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.
Complete Application Packet

All forms and instructions in a single PDF file - Clinical Laboratory Technologist & Certified Histological Technician Limited License Application Packet ( PDF 120 KB)

Form 1LL - Application for a Limited License Licensure ( PDF 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 ( 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 2A - Certification of Training/Experience ( PDF 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 ( PDF 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.

Last Updated: October 16, 2009