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Form 5B: Application for a Limited Permit for Applicants Who Have Not Applied for Licensure in New York

This application form is only for applicants requesting a limited permit who do not seek licensure in New York State. If you are seeking licensure and wish to apply for a Limited Permit, you must complete Form 5A.

In addition to Form 5B, the Department must receive the Certification of Professional Education (Form 2), the appropriate limited permit fee and proof that you have completed the required training in the identification and reporting of child abuse.

  • Section I: Complete all parts of this section before forwarding it to your prospective employer and be sure to have your signature notarized in item 23.
  • Section II: Your prospective employer completes Section II. Either you or your employer must return the form to the address listed on the form.

Note: You must complete the required coursework or training in the identification and reporting of child abuse and submit a certificate of completion from an approved provider or an exemption form.