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 appropriate licensing/certifying authority. Be sure to sign and date item 9. A separate Form 3 must be submitted for all licenses/certificates you have ever held except those issued by the New York State Education Department.
- 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. Also, If the certification/verification documentation provided by a U.S. jurisdictions contains the same information requested in the Form 3, completion of a Form 3 for that jurisdiction is not necessary. For certification/verification documentation that does not contain the same information, a Form 3 will need to be completed for that jurisdiction.
*Profession is defined as professional titles licensed under New York State Education Law.