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 ( PDF 45 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@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 $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 ( 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 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 - ( PDF 25 KB)
Use this form only if you are or have been licensed/certified in another jurisdiction.

  • 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.

Form 4 - Report of Professional Practice - ( PDF 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 - ( PDF 22 KB)

  • 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 - ( PDF 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.
Last Updated: April 8, 2014