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If you have held a New York State Limited License for Clinical Laboratory Technology or Certified Histological Technician DO NOT USE THIS FORM. Use Form 5PP ONLY.

All applicants for a provisional permit must complete this form and submit it with the appropriate provisional permit fee directly to the Office of the Professions at the address at the end of the form. 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 5N must be notarized by a Notary Public.

Address/Name Change Form - Optional (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.