This form must be submitted by the licensing authority.
Use this form if you are or ever have been licensed in another U.S. jurisdiction.
- Section I: Complete this section and forward this form to the licensing authority of the jurisdiction in which you are licensed. Ask the licensing authority to complete Section II and submit the completed form directly to the Office of the Professions at the address at the end of the form.
- Section II: An official from the licensing authority must complete this section and return the form directly to the Office of the Professions at the address at the end of the form.
Note: A separate Form 3 must be received from every state, province or country in which you are or ever have been licensed. 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
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