Speech-Language Pathology & Audiology
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 Acrobat Portable Document Format (PDF). To view or print these documents, you will need to have the free Acrobat Reader installed on your computer. Download times and print quality will depend on your connection speed and printer.
Form 1 - Application for Licensure and First Registration (sla1.pdf; 44K; 4 pages)
All applicants for licensure must complete this Form and submit it with the $294 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 (anchange.pdf; 24K; 2 pages)
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 (sla2.pdf; 22K; 2 pages)
If you received your graduate degree before April 1, 1976 you should 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 you attended.
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.
An official transcript must be attached for all graduates of non-registered or non-accredited programs. When studies were completed at more than one school, official transcripts must be sent to the Department from each school. Please photocopy the form as needed. In addition, graduates of these programs must also have official undergraduate transcripts sent in an official school envelope to the address on the form.
Form 4A - Identification of Supervisor and Setting (sla4a.pdf; 21K; 2 pages)
This form should be submitted at the beginning of your supervised experience. When the Application for Licensure and First Registration(Form 1), the fee, Certification of Professional Education (Form 2), and Identification of Supervisor and Setting (Form 4A) are received and approved, you will receive verification (Form 6) once your experience is approved. The Form 6 is required in some settings; therefore, it is important to submit Form 4A as soon as your experience setting has been established.
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.
Form 4B - Record of Supervised Experience (sla4b.pdf; 22K; 2 pages)
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.
If you completed your experience in the past and are certified by the American Speech-Language Hearing Association (ASHA), you may request ASHA to 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
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
10801 Rockville Pike
Rockville, MD 20852
Phone: 800-498-2071
E-mail: actioncenter@asha.org
Web: www.asha.org
