License Application Forms

Physician Assistant

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 ( PDF 40 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@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 $115 licensure 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. 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 23 KB)
This form must be submitted directly by the professional school you attended.

  • Section I: Complete this section of the form. Be sure to sign and date item 8 before sending it to your professional school.
  • Section II: Request the professional school to complete this section and attach an official transcript and send it directly to the Office of the Professions at the address at the end of the form. Be sure to include any fee required by the school.

Form 3 - Verification of Licensure/Certification in Another Jurisdiction ( PDF 22 KB)
Use this form only if you are or have been licensed/certified in another jurisdiction

This form must be submitted directly by the licensing authority.

  • Section I: Complete this section of the form before sending it to the licensing authority of each jurisdiction in which you are or have been licensed/certified. Be sure to include any fee required by the licensing authority and sign and date item 7.
  • Section II: The licensing authority must complete this section, sign, date and return the form directly to the Office of the Professions at the address at the end of the form.

Form 5 - Application for Limited Permit ( PDF 26 KB)

  • Section I: Complete this section of the form before sending it to your employer. Be sure to sign and date item 8 and include your limited permit fee of $105. If you have not yet filed the licensure application (Form 1) and fee, and any additional required documentation, you must do so before the Office of the Professions can review and approve your application for a limited permit.
  • Section II: Request the supervising physician to complete this section and return to you. Send this application and fees to the Office of the Professions at the mailing address at the end of the form.
Last Updated: April 7, 2014