Form 4 - Verification of Experience

This form must be submitted directly by at least two licensed professional colleagues.

• Section I: Complete this section and forward this form to at least two licensed professional colleagues to complete section II.
• Section II: Ask your professional colleagues to complete Section II and submit the completed form directly to the Office of the Professions at the address at the end of the form.

NOTE: A separate Form 4 must be received from each licensed colleague verifying your professional experience.

Electronic Verification of Experience

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*.

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.