This application form is only for applicants requesting a limited permit who also seek licensure in New York State.
If you have already submitted your application and fee for licensure and requested that the Certification of Professional Education (Form 2) be sent to the Department, you need only submit Form 5A and the appropriate fee for the limited permit. If you are not seeking licensure but still wish to apply for a Limited Permit, you must complete Form 5B.
- Section I: Complete all parts of this section before forwarding it to your prospective employer. Be sure to sign and date item 8.
- Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.
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