License Application Forms: Clinical Nurse Specialist

Instructions for completing and submitting the forms required for licensure appear below. 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.

Please type or print all information and sign all forms in black or blue ink. Original signatures are required on all forms.

Form 1 - Application for a Clinical Nurse Specialist Certificate ( PDF 22 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 a certificate must complete this form and submit it with the $80 fee for a certificate and initial 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.

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 (If applicable) ( PDF 17 KB)

For applicants who have completed a program registered by the State Education Department as qualifying for a certificate or a program determined by the Department to be equivalent.

This form must be submitted directly to the Office of the Professions by the professional school you attended. This form will not be accepted if submitted by the applicant or any party other than the school official.

  • Section I: Complete this section of the form before sending the entire form to your school. Be sure to sign and date item 11.
  • Section II: The Registrar 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.
Form 3 - Verification of Other Professional Licensure/Certification ( PDF 17 KB)
Complete this form if you hold, or have ever held, a license or certificate to practice as a clinical nurse specialist 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 9.
  • 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.

Form 3C - Verification of Clinical Nurse Specialist Certification ( PDF 16 KB)

For applicants seeking a New York State clinical nurse specialist certificate through a national certifying organization.

This form must be submitted directly to the Office of the Professions from the national certifying organization that will verify your certification. The Office of the Professions will not accept this form if submitted by the applicant or any other party.

  • Section I: Complete this section before sending the entire form to the national certifying organization to verify that you are certified. Be sure to sign and date item 9.
  • Section II: The national certifying organization 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.
 
Form 4 - Verification of Experience - ( PDF 17 KB)
For applicants following alternative requirements for a certificate before September 15, 2017.

  • Section I: Complete this section of the form before sending the entire form to the clinical supervisor who supervised your experience within the specialty for which you are seeking a certificate. Be sure to sign and date item 7.
  • Section II: The clinical supervisor 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.

A separate Form 4 must be submitted by each clinical supervisor with whom you worked with while acquiring the required experience.

 
Last Updated: August 11, 2014