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 Authorization ( PDF 25 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@mail.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 authorization to practice as a polysomnographic technologist must complete this form and submit it with the $600 fee for authorization 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 17 KB)
This form must be submitted directly by the professional school.
  • Section I: Complete this section of the form before sending it to your school. Please be sure to sign and date item 9.
  • Section II:Send the entire form to the institution(s) you attended and ask the registrar to complete Section II and forward all pages of the form directly to the Office of the Professions at the address at the end of this form. Be sure to include any fee required by the institution. This form will not be accepted if submitted by the applicant.
Form 3 - Verification of Other Professional Licensure/Certification - ( PDF 17 KB)
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.

NOTE: A Form 3 is not required for licenses/certificates issued by the New York State Education Department.

*Profession is defined as professional titles licensed under New York State Education Law. (See page 2 of the Address/Name Change Form ( PDF 20 KB) for a list of those titles.)

Form 4 - Report of Professional Experience - (For Applicants applying for authorization using the Grandparenting Method). Applications will only be accepted if submitted by November 3, 2014. ( PDF 16 KB)
Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date the attestation.

You must also complete a separate Verification of Professional Experience (Form 4A) for each supervised experience you list on the Report of Profession Experience (Form 4).

Form 4A - Verification of Professional Experience - (For Applicants applying for authorization using the Grandparenting Method). Applications will only be accepted if submitted by November 3, 2014. ( PDF 18 KB)
This form must be submitted directly by the supervisor(s) who supervised your experience. The Office of the Professions will not accept this form if submitted by the applicant.
  • Section I: Complete this section before giving the entire form to the supervisor(s) who supervised your experience. Be sure to sign and date item 7.
  • Section II: The supervisor(s) who supervised your experience 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.

Note: A separate Form 4A must be submitted for each supervised experience you list on Form 4.

Form 5 - Application for Limited Permit - ( PDF 18 KB)
  • Section I: Complete this section of the form. Please be sure to sign and date item 9.
  • Section II: Your prospective supervisor must complete this section. You must meet all other requirements for licensure except the examination requirement, in order to be eligible for a limited permit.

In addition to the Form 5 and $70 limited permit fee, you must also submit the Application for Authorization (Form 1), the $600 fee for authorization and first registration, and have the State Education Department approve your education before your application for a limited permit can be approved. Return the completed Form 5 to the Office of the Professions at the address at the end of the form.

Note: If the physician providing direction and supervision is not also the individual providing direct and immediate supervision, you will need to submit a separate Form 5 for each.


Last Updated: July 17, 2014