License Application Forms: Nurse Practitioner

Important Notice: If you were ever licensed in this profession in New York State STOP. 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 us to request a Delayed Registration Application, or call 518-474-3817 Ext. 570.

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Form 1 - Application for a Certificate ( PDF 23 KB)

All applicants for a nurse practitioner certificate must complete this form and submit it with the $85 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 28 KB)

For applicants who have graduated from a nurse practitioner education program registered by the State Education Department 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 2B - Verification of Instruction in New York State and Federal Laws Related to Prescriptions and Record Keeping - ( PDF 17 KB)

For applicants who have completed a program other than a program registered by the New York State Education Department as qualifying for a certificate.

This form must be submitted directly to the Office of the Professions by the school, institution or professional association where you completed instruction. This form will not be accepted if submitted by the applicant or any party other than the school, institution or professional association official.

  • Section I: Complete this section of the form before sending the entire form to the school, institution or professional association where you completed instruction in New York State and federal laws relating to prescriptions and record keeping. Be sure to sign and date item 8.
  • 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 2C - Verification of Pharmacotherapeutics Course - ( PDF 18 KB)

For applicants who have completed a program other than a program registered by the New York State Education Department as qualifying for a certificate.

This form must be submitted directly to the Office of the Professions by the school, institution or professional association where you completed instruction. This form will not be accepted if submitted by the applicant or any party other than the school, institution or professional association official.

  • Section I: Complete this section before sending the entire form to the school institution or professional association where you completed a pharmacotherapeutic course, including instruction in drug management of clients in the nurse practitioner's specialty area. Be sure to sign and date item 8.
  • 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 National Nurse Practitioner Examination ( PDF 18 KB)

For applicants seeking a New York State nurse practitioner 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 examination. 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 passed the nurse practitioner certification examination. 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 4NP - Verification of Collaborative Agreement and Practice Protocol - ( PDF 14 KB)
Note: Nurse practitioners (NPs) with more than 3,600 hours of experience as an NP licensed in any state or working for US Armed Forces, US Veterans Administration or the Public Health Service can choose to practice and have collaborative relationships instead of practicing in pursuant to a written practice agreement with a collaborating physician. Newly certified NPs (with more than 3,600 hours of qualifying NP experience) who choose to practice and have collaborative relationships as allowed by New York Law SHOULD NOT fill out Form 4NP.

All other newly certified NPs must fill out and submit Form 4NP to the Office of the Professions NO LATER than 90 days after the commencement of practice. This submission to the Office of the Professions is only required once.

  • Section I: Complete this section of the form.
  • Sections II & III: You and the initial collaborating physician with whom you have a practice agreement and practice protocol must complete these sections and return both pates of the form to the Office of the Professions at the address at the end of the form. Be sure to sign item 4 in Section III.

FORM NP-CR – Collaborative Relationships Attestation Form - ( PDF 14 KB)
This form must be filled out and signed by nurse practitioners (with more than 3,600 hours of qualifying nurse practitioner practice experience) who choose to practice and have collaborative relationships - instead of practicing in accordance with a written practice agreement with a collaborating physician. Once completed, a nurse practitioner must keep FORM NP-CR at the nurse practitioner's practice location and provide it to the New York State Education Department only upon request.

Nurse practitioners who practice in accordance with a written practice agreement with a collaborating physician SHOULD NOT fill out a FORM NP-CR.
Last Updated: December 4, 2018