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 43 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 and certification must complete and submit this form 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 19 KB)
This form must be submitted directly from the professional school.

  • Section I: Complete this section of the form before sending it to your educational institution. Be sure to sign and date item 10.
  • Section II: The Registrar must complete this section and return the form with an official transcript in a sealed school envelope directly to the Office of the Professions at the mailing address on the form.

Form 3 - Certification of Out of State Licensure and Examination Grades ( PDF 19 KB)
Use this form only if you are or have been licensed as a psychologist in another jurisdiction.

This form must be submitted directly by the licensing authority.

  • 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 as a psychologist. Be sure to sign and date item 8.
  • Section II: The licensing authority must complete this section, sign, date and return the form directly to the Office of the Professions at the mailing address on the form. A separate Form 3 must be submitted from each state where a license was granted.

Form 4 - Report of Professional Experience ( PDF 45 KB)
This form must be submitted directly by the supervising psychologist who provided supervision of the professional experience claimed by the applicant. Please see instructions, also contained on the PDF form, for further information.

  • Section I: Complete this section and send the form and Instructions for Completing the Report of Professional Experience (Form 4) to your supervising psychologist. Be sure to sign and date item 7.
  • Section II and III: The supervising psychologist must complete these sections, sign and date the form and return it directly to the Office of the Professions at the mailing address on the form.

Form 5A - Application for Limited Permit For Persons Gaining Experience For Licensure ( PDF 19 KB)
  • Section I: Complete this section and be sure to sign and date item 9.
  • Sections II and III: The supervising psychologist must review the instructions in Section II, complete Section III and sign and date the form before you return it to the Office of the Professions with your limited permit fee.

Form 5B - Application for Limited Permit For Persons Licensed In Other Jurisdictions ( PDF 19 KB)
  • Section I: Complete this section and be sure to sign and date item 9.

For either Form 5A or Form 5B: Return the completed form with the $70 fee to the Office of the Professions at the mailing address on the bottom of the form. If you have not already submitted your Application for Licensure (Form 1) and fee, you must do so before your limited permit application can be processed.

Last Updated: October 2, 2014