Use this form only if you are or have been licensed/certified in another jurisdiction
This form must be submitted directly by the licensing authority.
- Section I: Complete this section of the form before sending it to the licensing authority of each jurisdiction in which you are or have been licensed/certified. Be sure to include any fee required by the licensing authority and sign and date item 7.
- Section II: The licensing authority must complete this section, sign, date and return 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 U.S. jurisdiction 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.
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