License Application Forms

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 & First Registration ( PDF 41 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 $495 licensure and registration fee (and an additional fee of $370 for each additional specialty) 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)
Please note: This form must be submitted directly by the educational institution you attended.
  • Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 8. Be sure to include any fee required by the school. A separate Form 2 should be submitted for each educational program attended that will demonstrate satisfaction of the professional education requirement.
  • Section II: The Registrar or appropriate school official must complete this section and return the form in a school envelope directly to the Office of the Professions at the mailing address at the end of the form.
    • Graduates of Master's and Doctoral programs from accredited United States colleges or universities must send this form to each college/university where you attended a graduate level program and request that each school complete the appropriate parts of Section II of this form and return it directly to the Office of the Professions with an official transcript.
    • Graduates of Master's and Doctoral programs from colleges or universities located outside the United States and not accredited by a U.S. accreditation body must send this form to every college/university attended and request each school to complete the appropriate parts of Section II of this form and return it directly to the Office of the Professions with an official transcript.
 
Form 4 - Personal Affidavit of Professional Practice ( PDF 20KB)

Complete this form and send it to the address at the end of the form. Be sure to sign and date item 6 and list all professional medical physicist work experience chronologically, beginning with your first employer to the present. Provide the name and address of each employer and the specialty area you practiced with each employer. Attach additional sheets if needed.

You should transcribe the professional experience information, including a comprehensive description of your professional experience, from the Form 4 to an individual Form 4A for each endorser you list (for more information see Form 4A Instructions: PDF ( PDF 22KB) | HTML )

Form 4A - Verification of Professional Experience ( PDF 23 KB)

Instructions for Completing Verification of Professional Experience: PDF ( PDF 22 KB) | HTML

This form must be sent directly by the endorser.

  • Section I: Complete this section and forward the form, along with a copy of the instructions, to the individual endorser who will attest to your practice of medical physics. Be sure to sign and date the attestation.
  • Section II: Have your endorser complete this section, sign and date the attestation and send the form directly to the Office of the Professions to the address at the end of the form. This form will not be accepted if submitted by the applicant.
 
Form 5 - Application for Limted Permit - ( PDF 45 KB)
  • Section I: Complete this section before having your supervisor complete Section II. Be sure to sign and date item 18.
  • Section II: Have your supervisor complete Section II and return the completed form with the $60 fee to the Office of the Professions at the mailing address on the bottom of the form.

NOTE: A separate application (Form 5) is needed for each specialty you wish to apply for.

Last Updated: April 7, 2014