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.

Please type or print all information and sign all forms in black or blue ink. Original signatures are required on all forms.

Complete Application Packet
All forms and instructions in a single PDF file - Speech-Language Pathology and Audiology Licensing Application Packet ( PDF 137 KB)

Individual Application Forms

Form 1 - Application for Licensure ( PDF 26 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 licensure must complete this form and submit it with the $294 fee for licensure and first registration directly to the Office of the Professions at the 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 18 KB)
If you received your graduate degree before April 1, 1976, do not use this form. Have your school(s) send undergraduate and graduate transcripts to the Office of the Professions. Verification from school(s) must also include practicum information.

This form must be submitted directly by the educational institution. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 9.
  • Section II: The registrar or appropriate school official must complete this section, sign and date and return the form in an official school envelope directly to the Office of the Professions at the address at the end of the form.
 
Form 3 - Verification of Other Professional Licensure/Certification ( PDF 18 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 3A is not required for licenses/certificates issued by the New York State Education Department.

Please photocopy this form as needed.

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

Form 4A - Identification of Supervisor and Setting ( PDF 18 KB)
This form should be submitted at the beginning of your supervised experience. When the Application for Licensure (Form 1), the fee, Certification of Professional Education Form (Form 2), and Identification of Supervisor and Setting Form are received and approved, you will receive verification (Form 6).

If application is not made until after the supervised experience begins, or at the end of the experience, it is still necessary to complete and submit this form.

  • Section I: Complete this section and ask your employer and/or supervisor to complete Section II, Part A.
  • Section II: Complete parts B, C and D of this section with your employer and/or supervisor and then return the entire form directly to the Office of the Professions at the address at the end of the form.
 
Form 4B - Record of Supervised Experience ( PDF 18 KB)
Your supervisor must send this form directly to the Office of the Professions at the end of the supervised experience. The Office of the Professions will not accept this form if it is submitted by the applicant.
 
  • Section I: Complete this section before sending the entire form to your supervisor. Be sure to sign and date item 7 once the work experience is complete.
  • Section II: Your supervisor must review this section and complete the attestation then return both pages of the form directly to the Office of the Professions at the address at the end of the form.
 
If you completed your experience in the past and are certified by the American Speech-Language Hearing Association (ASHA), you may send a copy of the Clinical Fellowship Year (CFY) Plan and Report for consideration directly to the Office of the Professions at:

New York State Education Department
Office of the Professions
Division of Professional Licensing Services
Speech-Language Pathology and Audiology Unit
89 Washington Avenue
Albany, NY 12234-1000
Phone: 518-474-3817 ext. 270
Fax: 518-402-5354
E-mail: opunit3@mail.nysed.gov

 
However, Forms 4A and 4B are preferred, especially if the experience requirement was completed in New York State within the last five years. You may contact ASHA at:

ASHA
2200 Research Blvd.
Rockville, MD 20850-3289
Phone: 800-498-2071
E-mail: actioncenter@asha.org
Web: www.asha.org

Last Updated: April 9, 2014