Form 4B - Certification of Completion of Clinical Residency Program

This form must be submitted directly by your residency program director. The Office of the Professions will not accept this form if submitted by the applicant.

• Section I: Complete this section before giving the entire form to your residency program director. Be sure to sign and date item 6.
• Section II: The residency program director of the residency program you completed must complete this section and return both pages of the form directly to the Office of the Professions at the address located at the bottom of the form.

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.