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Form 4B - Certification of Supervised Experience

This form must be submitted directly by the licensed professional(s) who supervised your experience. 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 and a copy of Appendix A (PDF 21 KB) to the licensed professional(s) who supervised your experience. Be sure to sign and date item 9.
  • Section II: The licensed professional(s) who supervised your 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. The supervisor must be the supervisor named on your limited permit, for experience in New York.

A separate Form 4B must be submitted for each supervised experience you list on the Applicant Experience Record (Form 4).