Restricted License Application Forms

Clinical Laboratory Technologist

Important Notice: DO NOT use Form 1 if you are already licensed in this profession in New York State. 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. To renew your registration online, visit www.op.nysed.gov/renewalinfo.htm. If your registration has lapsed for longer than 4 months, submit a Delayed Registration Application.
Form 1 - Application for a Restricted License(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.

Change Address or Name  - You are required to notify us within 30 days of any address or name changes. Please read the instructions to request this change.

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.

Electronic Transcript Service

The Office of the Professions (OP) will accept official electronic transcripts from educational institutions (i.e. colleges/universities) or designated third-party* transcript entities located in the United States provided that:

  • The transcript is the certified true and official academic record and the document does NOT have an expiration date**.
  • OP can independently verify that the transcript is received directly from the educational institution’s registrar or officially designated third-party.
  • If a third-party transcript provider is involved, it is clear that the educational institution has designated the third party as the official sole provider of its transcripts.
  • The applicant had no opportunity to directly access or alter the transcript before it is sent or transmitted.
  • Any educational institution transcript submissions should be made electronically to DPLSEduc@nysed.gov***.

*OP will only accept third-party submissions after we have determined that the arrangement between the educational institution and the third party is consistent with our security and verification standards.

**Transcript documents with expiration dates cannot be accepted. Expirations on links to the document are acceptable.

***Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

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: A Form 3 is not required for licenses/certificates issued by the New York State Education Department. Also, If the certification/verification documentation provided by a U.S. jurisdictions contains the same information requested in the Form 3, completion of a Form 3 for that jurisdiction is not necessary. For certification/verification documentation that does not contain the same information, a Form 3 will need to be completed for that jurisdiction.

*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 4 - Attestation of Training Program Content in:

NOTE: Form 4 is required to obtain a certificate to participate in a particular training program. You may not begin a program until the application has been approved and a certificate has been issued.

This form must be submitted directly by the Clinical Laboratory Director of the training program in which you wish to participate. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section of the form.
  • Section II: Review and complete Section II with the Clinical Laboratory Director of the training program in which you wish to participate. Then ask the Clinical Laboratory Director to return the entire form to the Office of the Professions at the address at the end of the form. Be sure that both you and the Clinical Laboratory Director sign and date the attestations.

Form 4A - Certification of Completion of Training Program in:

This form must be submitted directly by the Clinical Laboratory Director of the training program that you completed. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section of the form before sending the entire form the Clinical Laboratory Director of the training program you completed. Be sure to sign and date item 7.
  • Section II: The Clinical Laboratory Director 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.

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

  • OP can independently verify that the documentation is received directly from the supervisor
  • The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
  • Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

Last Updated: April 9, 2020