License Application Forms
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- Form 1 - Application for Licensure ( 45 KB)
- All applicants for licensure must complete this form and submit it
with the $377 licensure fee directly to the Office of the Professions
at the mailing address at the end of Form 1. Applicants who are eligible
and wish to obtain DPA certification must check both boxes in item
1 of the form and include the additional $60 fee. Make your check 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 - ( 28 KB)
- This form
must be completed and submitted by the educational institution. The
Office of the Professions will not accept this form if it is submitted
by the applicant.
- Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 9.
- Section II: The Registrar must complete this section and
return the form directly to the Office of the Professions
at the mailing address on the form.
- Form 3 - Verification of Licensure/Certification in Another Jurisdiction - ( 25 KB)
- Use this form only if you are or have been licensed/certified in another
- 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 sign and date item 7 and include any fee required by the licensing authority.
- 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 4 - Report of Professional Practice - ( 15 KB)
- Use this form only if you are licensed in another jurisdiction and are
seeking licensure by endorsement.
Complete this form and provide a chronological list of your professional practice in item 5 including the name and practice address of the licensed optometrist(s) who will attest to your practice. Be sure to sign and date item 6.
You must send a corresponding Form 4A to each optometrist you list in item 5.
- Form 4A - Supporting Affidavit
of Professional Practice - (
- Section I: Complete this section of the form and send it to the licensed optometrist(s) who will verify your professional practice. Be sure to sign and date item 7. You may need to have more than one affidavit submitted for comprehensive certification of the required five years of professional optometry practice. Please photocopy the form as needed
- Section II: The licensed optometrist(s) who will verify your professional
practice must complete and submit the form directly to the Office of
the Professions at the address at the end of the form.
- Child Abuse Certification of Exemption Form - ( 17 KB)
- This form is not for all applicants. Use this form only if you are applying for an exemption to the requirement to complete training or coursework in the identification of child abuse and maltreatment because the nature of your practice excludes contact with persons under the age of 18 and persons 18 or older with a handicapping condition who reside in a residential care school or facility.