Provisional Permit Application Forms

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Form 5N - Application for Provisional Permit ( PDF 668 KB)
If you have held a New York State Limited License for Clinical Laboratory Technology or Certified Histological Technician DO NOT USE THIS FORM. Use Form 5PP ONLY.

All applicants for a provisional permit must complete this form and submit it with the appropriate provisional permit fee directly to the Office of the Professions at the address at the end of the form. 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 5N 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 2PP - Certification of Professional Education ( PDF 580 KB)

If you have held a New York State Limited License for Clinical Laboratory Technology or Certified Histological Technician DO NOT USE THIS FORM. Use Form 5PP ONLY.

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 3PP - Verification of Other Professional Licensure/Certification ( PDF 604 KB)
If you have held a New York State Limited License for Clinical Laboratory Technology or Certified Histological Technician DO NOT USE THIS FORM. Use Form 5PP ONLY.

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.

Form 4PP - Certification of Training/Experience ( PDF 595 KB)
This form is for Clinical Laboratory Technologist Provisional Permit applicants ONLY.

If you have held a New York State Limited License for Clinical Laboratory Technology or Certified Histological Technician DO NOT USE THIS FORM. Use Form 5PP ONLY.


This form must be submitted directly by the Clinical Laboratory Director/Principal Reseacher 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 the entire form to the Clinical Laboratory Director/Principal Reseacher of the clinical or research laboratory where you received your training/experience. Be sure to sign and date item 8.
  • Section II: The Clinical Laboratory Director/Principal Reseacher 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.
Last Updated: December 6, 2018