License Application Forms: Nurse Practitioner

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 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.

Complete Application Packet

All forms and instructions in a single PDF file - Nurse Practitioner Application Packet ( 152 KB)

 

Form 1 - Application for a Certificate ( 23 KB)

All applicants for a 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 ( 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) ( 28 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 2B - Verification of Instruction in New York State and Federal Laws Related to Prescriptions and Record Keeping - ( 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 - ( 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 ( 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 4 - Verification of Experience - ( 20 KB)

For applicants following pre-1989 alternative requirements for a certificate.

This form is required within 90 days after commencement of practice.

• Section I: Complete this section of the form before sending the entire form to the physician 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 supervising physician 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 physician with whom you worked with while acquiring the required experience.

Form 4NP - Verification of Collaborative Agreement and Practice Protocol - ( 14 KB)

Form 4NP is NOT required to obtain a certificate, but MUST be submitted to the Office of the Professions NO LATER than 90 days after commencement of practice. This submission to the Department is only required once.

• Section I: Complete this section of the form.
• Section 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 pages 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.