License Application Forms

Physician

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.
Form 1 - Application for Licensure and First Registration ( PDF 44 KB)

Important Notice: 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. If your registration has lapsed and you need to reregister, do not submit a Form 1. Instead, contact the Registration and Fees Unit to request a Delayed Registration Application by e-mailing: OPREGFEE@mail.nysed.gov, or by calling 518-474-3817 Ext. 410.  When e-mailing, be sure to include your profession, license number, address on record, new address (if changed), date of birth and the last 4 digits of your SSN.

All applicants for licensure must complete this form and submit it with the $735 licensure and registration fee directly to the Office of the Professions at the mailing address at the end of Form 1. Make checks payable to the New York State Education Department. 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 and Preprofessional Education ( PDF 21 KB)
PLEASE NOTE: If you are not using FCVS, you must have your educational institution send this form directly to the Office of the Professions. We will not accept this form if it is submitted by the applicant or a third party.

Graduates of programs not registered as licensure qualifying by New York State or accredited by the Liaison Committee on Medical Education (LCME), or the American Osteopathic Association (AOA) - do not use this form. You must use FCVS to collect your credentials.

  • Section I: Complete this section of the form before sending it to your professional school. If you graduated from a medical school that was not registered by New York State or accredited by LCME/AOA, notify the school that a transcript must accompany the form. If you attended a medical school that has been closed, send this form to the official repository of the records for that school; e.g., CONES.
  • Section II: The Registrar, Dean, Rector, or Principal of the medical school must complete the appropriate parts of this section and return the form directly to the Office of the Professions in an official school envelope at the address on the form.

Please make as many copies of Form 2 as needed.

Form 2CC - Certification of Approved Clinical Clerkship ( PDF 15 KB)
Use this form only if you are a graduate of a non-LCME-accredited medical school located in one country but completed one or more clinical clerkships in another country.

Please Note: This form must be mailed directly to the Office of the Professions by the hospital in its identifying envelope. We will not accept this form if it is submitted by the applicant or a third party.

Form 2CC is not needed for graduates of the following medical schools, which have been approved by the New York State Education Department to allow students to complete more than 12 weeks of clinical clerkships in New York State. The schools are:

  • American University of Antigua, Antigua
  • American University of the Caribbean, St. Martin, Netherland Antilles
  • The Autonomous University of Guadalajara, Guadalajara, Mexico
  • English Language Program, University of Debrecen, Medical and Health Science Center, Medical School, Debrecen, Hungary
  • English Language Program, Medical University of Lublin, Lublin, Poland
  • English Language Program, Medical University of Silesia, Katowice, Poland
  • Fatima College of Medicine, Manila, Philippines
  • International Health and Medicine Program, Ben Gurion University of the Negrev, Beer-Sheva, Israel
  • Kasturba Medical College, Manipal, India
  • Medical University of the Americas/Nevis, Nevis, West Indies
  • Ross University School of Medicine, Roseau, Dominica
  • Saba University School of Medicine, Saba, Netherland Antilles
  • St. George's University School of Medicine, St. George's, Grenada
  • St. Matthew's University School of Medicine, Grand Cayman, Cayman Islands

Former students of CIFAS, CETEC, and UTESA should not use Form 2CC. These applicants should request special clerkship verification forms from the Office of the Professions, Bureau of Comparative Education at (518) 474-3817 ext. 300 or by e-mail at comped@mail.nysed.gov.

  • Section I: Complete this section of the form before sending it to the hospital where you completed your clinical clerkship.
  • Section II: The Director of Medical Education or Department Chair must complete this section and return the form directly to the Office of the Professions at the address on the form.

Please make as many copies of Form 2CC as needed.

Form 2PGT - Certification of Approved Postgraduate Training* ( PDF 19 KB)
Use this form only if you are not using FCVS.

Please Note: This form must be mailed directly to the Office of the Professions by the hospital in its identifying envelope. Documentation of postgraduate training can only be accepted if signed less than one month prior to the completion date of the training period for which credit is sought. If you or a third party send this form, we will take no further action until we receive direct verification from the hospital.

  • Section I: Complete this section of the form before sending it to the hospital where you completed your postgraduate training.
  • Section II: The Director of Medical Education or Department Chair must complete this section and return the form directly to the Office of the Professions at the address on the form.

Please make as many copies of Form 2PGT as needed.

*Approved by the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, or the Royal College of Physicians and Surgeons of Canada.

Form 3A - Verification of Medical Licensure in Another Country ( PDF 15 KB)
Use this form only if you were licensed and practiced medicine in another country within the 5-year period immediately prior to the date of your application for licensure or a limited permit in New York State.

Please Note: This form must be sent to the Office of the Professions by the licensing jurisdiction. We will not accept this form if it is submitted by the applicant or a third party.

  • Section I: Complete this section of the form before sending it to the licensing authority of each country in which you were licensed to practice medicine within the 5-year period immediately prior to the date of your application for licensure in New York State.
  • Section II: The appropriate official of the licensing authority must complete this section and return the form directly to the Office of the Professions at the address on the form.

Please make as many copies of Form 3A as needed.

Form 3B - Verification of Pre-1972 Medical Licensure in Another U.S. State or Territory ( PDF 18 KB)
Use this form only if you are requesting endorsement of a medical license based on a pre-1972 state licensing examination.

Please Note: This form must be sent to the Office of the Professions by the licensing jurisdiction. We will not accept this form if it is submitted by the applicant or a third party.

  • Section I: Complete this section of the form before sending it to the state licensing authority where you took your pre-1972 state licensing examination.
  • Section II: The appropriate official of the licensing authority must fully complete this section and return the form directly to the Office of the Professions at the address on the form.
Form 4 - Verification of Professional Practice of Medicine in Another Jurisdiction ( PDF 17 KB)
Use this form only if you are requesting licensure based on endorsement of another license.

Please Note: This form must be sent to the Office of the Professions by the licensed physician verifying your practice. We will not accept this form if it is submitted by the applicant.

  • Section I: Complete this section of the form before sending it to the licensed physician verifying your professional practice of medicine. More than one form may be necessary to verify the total number of years of professional practice required for endorsement.
  • Section II: The licensed physician must complete this section and return the form directly to the Office of the Professions at the address on the form.

Please make as many copies of Form 4 as needed.

Form 5A or 5B - Application for a Limited Permit

Form 5A - Application for Limited Permit ( PDF 23 KB)
This application form is only for applicants requesting a limited permit who also seek licensure in New York State.

You must have already submitted your application and fee for licensure and arranged to have the other required documentation sent to us. You need only submit Form 5A and the appropriate limited permit fee.

  • Section I and II: Complete all parts of these sections before forwarding it to your prospective employer.
  • Section III: Your prospective employer completes Section III. Either you or your employer must send the completed form and fee to the Office of the Professions at the address listed on the form.

Please Note: If you did not complete the required coursework or training in the identification and reporting of child abuse as part of your educational program, you must submit either a Certificate of Completion from an approved provider or a Certificate of Exemption Form.

Form 5B - Application for Limited Permit ( PDF 34 KB)
This application is only for applicants requesting a limited permit who do not seek licensure in New York State.

In addition to Form 5B, you must submit the appropriate limited permit fee and arrange to have the other required documentation sent to us.

  • Section I and II: Complete all parts of these sections before forwarding it to your prospective employer.
  • Section III: Your prospective employer completes Section III. Either you or your employer must send the completed form and fee to the Office of the Professions at the address listed on the form.

Please Note: If you did not complete the required coursework or training in the identification and reporting of child abuse as part of your educational program, you must submit either a Certificate of Completion from an approved provider or a Certificate of Exemption Form.

Certification of Fifth (5th) Pathway Program ( PDF 15 KB)
Use this form only if you are requesting licensure under the fifth pathway program option, are not using fcvs and will send form 1 and fee on or before november 30, 2002.

Please Note: This form must be sent to the Office of the Professions by the Director of the Fifth Pathway Program. We will not accept this form if submitted by the applicant or a third party.

  • Section I: Complete this section before sending it to the Director of your Fifth Pathway Program.
  • Section II: The Director must complete this section and return the form directly to the Office of the Professions at the address listed on the form.

Last Updated: April 7, 2014