License Application Forms

Important Notice: DO NOT use Form 1 if you are already licensed in this profession in New York State. 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. To renew your registration online, visit www.op.nysed.gov/renewalinfo.htm. If your registration has lapsed for longer than 4 months, submit a Delayed Registration Application.

Note: For fillable PDF forms, Internet Explorer is the recommended browser.

Online Form 1 - Application for Licensure
All applicants for licensure must initially submit Form 1 along with the $339 licensure and first registration fee. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Change Address or Name  - You are required to notify us within 30 days of any address or name changes. Please read the instructions to request this change.

Online Form 1A - Special Provisions Form
Use this form ONLY if you have applied for licensure prior to January 1, 2022, but did not obtain licensure by not meeting the Part III examination requirement. Applicants seeking licensure in New York State for the first time should not use this form. But should apply using the Form 1.

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. You must sign and date the Affidavit on this form in the presence of a Notary Public.

Form 2 - Certification of Professional Education ( PDF 21 KB)

This form must be submitted directly by the educational institution.

  • Section I: Complete this section of the form before sending it to your school.
  • Section II: If you graduated from a pharmacy program that was accredited by ACPE, the registrar must complete this section. Applicants who are expected to graduate from these programs should forward this form to their academic institution for completion of Section II. The registrar must return the completed form directly to the New York State Education Department.

Part B is for all other programs. Applicants who are graduates of these programs should forward this form to their academic institution for completion of Section II. The Registrar must return the completed form directly to the New York State Education Department along with an official transcript.

Electronic Education Documentation

The Office of the Professions (OP) will accept official electronic transcripts and forms from educational institutions (i.e. colleges/universities) or designated third-party* transcript entities located in the United States or Canada provided that:

  • The transcript is the certified true and official academic record and the document does NOT have an expiration date**.
  • OP can independently verify that the documentation is received directly from the educational institution’s registrar or officially designated third-party.
  • If a third-party transcript provider is involved, it is clear that the educational institution has designated the third party as the official sole provider of its transcripts.
  • The applicant had no opportunity to directly access or alter the transcript before it is sent or transmitted.
  • Any educational institution education documentation submissions should be made electronically to DPLSEduc@nysed.gov***.

*OP will only accept third-party submissions after we have determined that the arrangement between the educational institution and the third party is consistent with our security and verification standards.

**Transcript documents with expiration dates cannot be accepted. Expirations on links to the document are acceptable.

***Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

Form 4 - Certification of an Internship in Pharmacy ( PDF 25 KB)
This form is not required for PharmD graduates from ACPE or CCAPP accredited programs.

Use Form 4 to certify the completion of the required internship, which can only be performed under an authorized permit. A separate Form 4 is required for each pharmacy, and for each preceptor and should be completed, signed by both intern and preceptor, and returned to the Department at the address at the end of the form. Pharmacy payroll records may be requested during periodic routine audits.

Department must receive Form 4 and approve the internship certification before you will be admitted to the MPJE. Incomplete forms or failure to comply with the internship requirement will prevent your admission to the exam.

  • Section I: Please complete this section of the form before submitting it to your preceptor pharmacist.
  • Section II: Your preceptor pharmacist must complete this section.
  • Section III: You and your preceptor pharmacist must sign in this section, affirming that the statements in Section I and Section II are true.
  • Section IV: If you are seeking credit for an internship completed in another state, submit this form to the authorized representative of that State's Board of Pharmacy for verification.

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

  • OP can independently verify that the documentation is received directly from the supervisor
  • The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
  • Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

Form 5 - Application for a Limited (Intern) Permit ( PDF 27 KB)

You must obtain an intern permit before engaging in the supervised practice of pharmacy in New York. Answer all questions on Form 5 and send it with your fee of $70 to the New York State Education Department. Be sure to sign item 10 and have your signature notarized by a notary public.

  • If you are a student in an accredited pharmacy program, the school must certify that you have completed at least the third year of a five- or six-year curriculum by completing the back of the Form 5.
  • If you are a graduate from a non-accredited program, do not submit Form 5 until after you have passed NAPLEX.
Last Updated: December 31, 2021