Form 5 - Application For Limited Permit - The State Education Department

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The University of the State of New York
Department Use Only
Nurse Form 5
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
Application for Limited Permit
APPLICANT INSTRUCTIONS
1.
A limited permit authorizes practice as a nurse under the immediate and personal supervision of a New York State
licensed, currently registered, registered professional nurse and with the endorsement of the employer. Complete
Section I. Be sure to sign and date item 11 on page 2. It is your responsibility to ensure that your prospective
employer fully completes Section II. Note: Once a limited permit is issued, it may not be adjusted. You should be
certain you are ready to begin practice when you apply for the limited permit. You may not begin practice until your
Date Approved/Rejected
limited permit is issued unless you meet the practice exemption detailed in the Instructions to the Employer in
Section II of this form.
2.
You may apply for a limited permit either at the same time as or after submitting an Application for Licensure (Form
1). If you have not yet filed a Form 1 and the licensure fee ($143), you must submit them with this form and the
Permit number
limited permit fee. Permits cannot be issued until all required documentation has been received and
approved.
3.
Submit this application and the $35 fee to the Office of the Professions, at the address at the end of this form.
Date issued
4.
If you change employment after your permit is issued, you must obtain a new permit by completing a new Form 5
with your prospective employer. A new fee is not required for a permit issued as a result of a change in employment.
Section I: Applicant Information
Date expires
1
Check what you are applying for:
Initials
22
$35
PR
Registered Professional Nurse (Limited Permit)
10
$35
PR
Licensed Practical Nurse (Limited Permit)
6
Telephone/E-Mail Address
2
Social Security Number
Daytime Phone
(Leave this blank if you do not have a U.S. Social Security Number)
3
Birth Date
Month
Day
Year
Area Code
Phone Number
4
Print Name
E-Mail Address (Please print clearly)
Last
First
Middle
7
I am applying for:
Mailing Address (You must notify the Department promptly of any address or name changes.)
5

Original permit
Line 1

Additional supervisor/
employer
Line 2

Change of supervisor/
Line 3
employer
City
State
Zip Code
Country/
Province
8
Are you licensed as a nurse in another jurisdiction?
Yes
No
If no, have you ever failed the RN licensing examination?
Yes*
No
If no, have you ever failed the PN licensing examination?
Yes**
No
*You are not eligible for an RN permit if you have ever taken the NCLEX-RN examination.
**You are not eligible for an LPN permit if you have ever taken the NCLEX-PN examination.
9
FOREIGN EDUCATED NURSES ONLY Have you successfully completed: (Check one)
CGFNS
CNATS
Date CGFNS Qualifying Examination written _______ / _______ / _______
*CGFNS Certificate No. ___________________________________
Date CNATS Examination written _______ / _______ / _______
CNATS Exam Score ______________________________________
* CGFNS must submit this certificate directly to the Office of the Professions.
10
Name and address of nursing school attended ___________________________________________________________________________________
____________________________________________________________________________ Date degree completed _______ / _______ / _______
mo.
day
yr.
Nurse Form 5, Page 1 of 3, Rev. 8/15

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