Use this form ONLY if you have applied for licensure prior to January 1, 2022, but did not obtain licensure by not meeting the Part III examination requirement. Applicants seeking licensure in New York State for the first time should not use this form. But should apply using the Form 1.
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. You must sign and date the Affidavit on this form in the presence of a Notary Public.
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