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 658 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 our customer services unit to request a Delayed Registration Application by e-mailing: op4info@nysed.gov, or by calling 518-474-3817 Ext. 570. 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 $200 fee for licensure and first registration directly to the Office of the Professions at the mailing 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 - ( PDF 572 KB)
This form must be submitted directly by the educational institution(s) you attended. 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 your institution(s). Be sure to sign and date item 9.
  • Section II: The Registrar must complete this section and return all pages of the form directly to the Office of the Professions at the address at the end of the form.

From 3 - Verification of Other Professional Licensure/Certification - (PDF568KB)
Complete this form if you hold, or ever held, a license or certificate to practice any profession* 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 8.
  • 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.

* Profession is defined as one of the professional titles licensed under New York State Education Law.

NOTE: This form is to verify other professional licensure only and should NOT be used to verify New York City Certification of Qualification or any affiliations with professional associations or organizations. A Form 3 is not required for licenses/certificates issued by the New York State Education Department.

Form 4 - Verification of Practice - ( PDF 566 KB)
Use this form only if you are applying for licensure under the Grandparenting Licensure Pathway which is available until November 28, 2019. This form must be submitted directly by the physician* who supervised your performance of the duties of a pathologists' assistant for two of the five years prior to November 28, 2017. 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 supervising physician. 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 for each instance of practice used towards meeting the Grandparenting requirements.

*The supervising physician must be a licensed physician practicing anatomic pathology.

Form 5 - Application for a Limited Permit - ( PDF 569 KB)
  • Section I: If you are applying for a limited permit, complete this section before having your prospective supervising physician* complete Section II. Be sure to sign and date item 9.
  • Section II: Have your supervising physician complete Section II.

Return the completed form with the $105 fee to the Office of the Professions at the address at the end of the form.

*The prospective supervising physician must be a licensed physician practicing anatomic pathology.

Last Updated: December 4, 2017