Form 4E - Affidavit of Professional Practice for Endorsement Applicants

This form must be submitted directly by the licensed speech-language pathologist or audiologist who will endorse your license application. The Office of the Professions will not accept this form if submitted by the applicant. This form is to be used only by individuals already licensed as a Speech-Language Pathologist or Audiologist in another state or jurisdiction.

• Section I - Complete this section and forward this form to the licensed speech-language pathologist or audiologist who will endorse your licensure application (the endorser must be licensed in the jurisdiction where you were employed). Be sure to sign and date item 7.
• Section II - The endorser must complete this section and return the entire form to the Office of the Professions at the address at the end of the form.

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

• OP can independently verify that the documentation is received directly from the supervisor
• The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
• Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.