Provisional Permit Application Forms for Histotechnician

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.

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.

This form must be submitted directly by the educational institution(s) you attended. 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 your school. Be sure to sign and date item 9.
• Section II: The Registrar must complete this section and return both pages of the form in a school envelope with requested documents directly to the Office of the Professions at the address at the end of the form.

Electronic Education Documentation

The Office of the Professions (OP) will accept official electronic transcripts and forms from educational institutions (i.e. colleges/universities) or designated third-party* transcript entities located in the United States provided that:
 

• The transcript is the certified true and official academic record and the document does NOT have an expiration date**.
• OP can independently verify that the documentation is received directly from the educational institution’s registrar or officially designated third-party.
• If a third-party transcript provider is involved, it is clear that the educational institution has designated the third party as the official sole provider of its transcripts.
• The applicant had no opportunity to directly access or alter the transcript before it is sent or transmitted.
• Any educational institution education documentation submissions should be made electronically to DPLSEduc@nysed.gov***.

*OP will only accept third-party submissions after we have determined that the arrangement between the educational institution and the third party is consistent with our security and verification standards.

**Transcript documents with expiration dates cannot be accepted. Expirations on links to the document are acceptable.

***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.

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.

Complete this form if you hold, or have ever held, a license or certificate to practice any profession* in a US 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 licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
• 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. 

NOTE: This form is to verify other professional licensure only and should NOT be used to verify New York City Certification of Qualification or any affiliations with professional associations or organizations.

This form is for Clinical Laboratory Technologist Provisional Permit applicants ONLY.

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.

This form must be submitted directly by the Clinical Laboratory Director/Principal Reseacher of the clinical or research laboratory where you received your training/experience. 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 Clinical Laboratory Director/Principal Reseacher of the clinical or research laboratory where you received your training/experience. Be sure to sign and date item 8.
• Section II: The Clinical Laboratory Director/Principal Reseacher 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.

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.