Complete this form if you hold, or ever held, a license or certificate to practice any profession* in any jurisdiction.
This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.
- Section I: Complete this section before sending the entire form to the licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
- Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of 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 a 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.
Please photocopy this form as needed.
*Profession is defined as professional titles licensed under New York State Education Law. (See page 2 of the Address/Name Change Form at the end of this packet for a list of those titles.)
Electronic Verification of Licensure, Certification and/or Examination
The Office of the Professions (OP) will accept electronic verifications of licensure, certification and examination completion from other licensing authorities located in the United States provided that:
- OP can independently authenticate that the verification is received directly from the licensing authority.
- The applicant had no opportunity to directly access or alter the verification before it is sent or transmitted.
- Any licensing authority verification submissions should be made electronically to DPLSVerif@nysed.gov.*
*DO NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.