License Application Forms
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- Form 1 - Application for Licensure ( 40 KB)
- 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 ( 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 2 - Certification of Professional Education ( 23 KB)
- This form must be submitted directly by the professional school you
- 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 ( 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 5 - Application
for Limited Permit ( 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.