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 or the podiatric ankle surgery privilege 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.

Podiatrist License Application Forms | Podiatric Ankle Surgery Privilege Application Forms

Form 1 - Application for Licensure ( PDF 46 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 licensure and registration fee 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 26 KB)
This form must be completed and submitted by the educational institution.

  • Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 8.
  • Section II: The Registrar must complete the appropriate parts of this section and return the form directly to the Office of the Professions at the address on the form.

Please make as many copies of Form 2 as needed.

Form 3 - Certification of Podiatry Licensure in Another Jurisdiction ( PDF 23 KB)
This form must be submitted by the licensing authority.

Use this form if you are or ever have been licensed in another U.S. jurisdiction.

  • Section I: Complete this section and forward this form to the licensing authority of the jurisdiction in which you are licensed. Ask the licensing authority to complete Section II and submit the completed form directly to the Office of the Professions at the address at the end of the form.
  • Section II: An official from the licensing authority must complete this section and return the form directly to the Office of the Professions at the address at the end of the form.

Note: A separate Form 3 must be received from every state, province or country in which you are or ever have been licensed.

Form 4pgy - Certification of Approved Podiatric Postgraduate Training ( PDF 24 KB)

  • Section I: Complete this section before forwarding it to the Director of Podiatric Medical Education at each hospital in which you completed approved post-graduate podiatric residency training.
  • Section II: The Director of Podiatric Medical Education must complete this section and return the form directly to the Department. Certification of approved postgraduate podiatric residency programs will be accepted only if they are signed no more than one month prior to the completion date of the residency training program and submitted to the Department directly from the Director of Podiatric Medical Education.

Please make as many copies of Form 4PGY as needed.

Form 5A or 5B - Application for a Limited Permit

Form 5A: ( PDF 25 KB)
This application form is only for applicants requesting a limited permit who also seek licensure in New York State.

If you have already submitted your application and fee for licensure and requested that the Certification of Professional Education (Form 2) be sent to the Department, you need only submit Form 5A and the appropriate fee for the limited permit. If you are not seeking licensure but still wish to apply for a Limited Permit, you must complete Form 5B.

  • Section I: Complete all parts of this section before forwarding it to your prospective employer. Be sure to sign and date item 8.
  • Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.

Form 5B: ( PDF 50 KB)
This application form is only for applicants requesting a limited permit who do not seek licensure in New York State. If you are seeking licensure and wish to apply for a Limited Permit, you must complete Form 5A.

In addition to Form 5B, the Department must receive the Certification of Professional Education (Form 2), the appropriate limited permit fee and proof that you have completed the required training in the identification and reporting of child abuse.

  • Section I: Complete all parts of this section before forwarding it to your prospective employer and be sure to have your signature notarized in item 23.
  • Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.

Note: You must complete the required coursework or training in the identification and reporting of child abuse and submit a certificate of completion from an approved provider or an exemption form.

Form 5C or 5D - Application for a Limited Residency Permit

Effective July 1, 2011: You must pass both Parts I and II of the National Board examinations prior to beginning a post-graduate podiatric residency program. Therefore, if this is the first time you are applying for a Limited Residency Permit (an original permit), you will have to achieve passing scores on both examinations before you can be issued a permit. This requirement does not apply if you are already in a residency program.
Form 5C: ( PDF 22 KB)
This application form is only for applicants requesting a limited residency permit who also seek licensure in New York State. If you are not applying for licensure or are already licensed in New York State, you must use Form 5D to apply for a limited residency permit.

  • Section I: Complete all parts of this section before forwarding it to your prospective employer and be sure to have your signature notarized in item 15.
  • Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.

Form 5D: ( PDF 28 KB)
This application form is only for applicants requesting a limited residency permit who are not seeking licensure in New York State. If you are applying for licensure, you must use Form 5C to apply for a limited residency permit.

  • Section I: Complete all parts of this section before forwarding it to your prospective employer and be sure to have your signature notarized in item 24.
  • Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on 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 children.

Note: You must complete the required coursework or training in the identification and reporting of child abuse and submit a certificate of completion from an approved provider or an exemption form.


Podiatric Ankle Surgery Privilege Application Forms

Form 1PODPR - Application for Podiatric Ankle Surgery Privilege (PDF 17 KB)
This application form is for applicants for Podiatric Ankle Surgery Privileges. Do not submit this form until you have completed all requirements for the privilege. You must answer all questions and provide all information requested unless otherwise indicated. Submit this form along with the licensure and first registration fee of $430 to the Office of the Professions at the address at the end of the form. Your signature on Form 1PODR must be notarized by a Notary Public.

Form 4PODPR - Attestation of Completion of an Accredited Residency Program in Podiatric Medicine and Surgery (PDF 16 KB)
  • Section I: Enter your name as it appears on your New York State podiatry license. Be sure to sign and date item 8. Send this form to the Program Director of the residency program in podiatric medicine and surgery and ask that they complete Section II.
  • Section II: The residency program must complete this section and submit this form directly to the New York State Education Department. If the residency program does not have a Program Director, the form may be completed by the department chair. If the Education Department cannot determine that this form came directly from the residency program, you will not receive credit for the program. This form will not be accepted if submitted by the applicant.

Form 4PODPRA - Applicant Training and Experience Record (PDF 16 KB)
Complete both pages of this form. In item 3, enter your name exactly as it appears on your New York State podiatry license. Be sure to sign and date item 8 and send this form directly to the Office of the Professions at the address at the end of this form.

You must also complete Section I of Form 4PODPRB and forward the entire form to each individual you list on page 2 of this form.

Form 4PODPRB - Certification of Training and Experience (PDF 14 KB)
  • Section I: Enter your name as it appears on your New York State Podiatry License. Be sure to sign and date item 6. Send this entire form to the individual(s) listed on Form 4PODPRA to complete Section II. If additional copies are needed, you may photocopy this form. Send a Form 4PODPRB to:
    1. For procedures done during residency, the Program Director of your residency program.
    2. For procedures done under an ankle surgery limited permit, the supervisor(s) of the procedures.
    3. For procedures completed in other circumstances, the Chief of Service of the appropriate department of the facility in which the procedure was performed.
  • Section II: The individual(s) certifying training and experience must complete Section II and return both pages of the form directly to the Office of the Professions at the address at the end of the form. The form must bear an original notarized signature of the individual(s) and date(s). This form will not be accepted if returned by the applicant.

Form 5PODPR - Application for Ankle Surgery Limited Permit (PDF 24 KB)
  • Section I: Complete Section I in ink and be sure to have your signature notarized in item 12. Your prospective supervisor must complete Section II. If you have more than one supervisor or change supervisors, submit a Form 5PODPR for each one and check the appropriate box in Item 8.
  • Section II: Request your prospective supervisor to complete this section and return the form to you. Send this application and the appropriate fee ($105 for an original permit, $50 for a renewal) to the Office of the Professions at the mailing address at the end of the form.
Last Updated: October 2, 2014