This form is for applicants seeking licensure in New York State by endorsement of a license to practice clinical social work issued in another jurisdiction. You must have at least 10 years of licensed experience in clinical social work, in the 15 year period prior to applying for licensure in New York State.
This form must be submitted by the licensed colleague who is attesting to your experience as a licensed clinical social worker in another jurisdiction. The Office of the Professions will not accept this form if submitted by the applicant.
- Section I: Complete this section and send the entire form to the licensed colleague who will attest to your experience as a licensed clinical social worker in another jurisdiction. Be sure to sign and date item 6.
- Section II: The licensed colleague who will attest to your licensed experience must complete this section and return both pages of the form directly to the Office of the Professions at the address at the end of the form.
A separate Form 4F must be submitted for each licensed colleague listed on the Endorsement Applicant Experience Record (Form 4E)
Important Information About Electronic Verification of Experience
The Office of the Professions (OP) will accept experience forms directly from supervisors that meet certain criteria. More information can be found here.