Form 5 - Application For Limited Permit - The State Education Department Page 3
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3Section II: Certification of Supervision (Continued)
6.
SUPERVISOR OF THIS PERMITTEE
In order to assure that there is always a licensed registered professional nurse available to work directly with this permittee on the specific unit, you
must provide the names of two licensed registered professional nurses who will supervise this permittee:
1.
Supervising registered professional nurse ________________________________________________________________________________
New York State License number ____________________________
2.
Supervising registered professional nurse ________________________________________________________________________________
New York State License number ____________________________
7.
ATTESTATION BY DIRECTOR OF NURSING OR PHYSICIAN
(To be completed and signed by the director of nursing or designee where the permittee will practice)
By completing the information in Section II and signing this attestation, I am certifying that the permittee will be employed under the supervision of a
registered professional nurse who is licensed and currently registered in New York State, that the supervising nurse will be notified of this
responsibility, and that the employer agrees to abide by the conditions stipulated on the permit.
I declare that the statements made in Section II are true, complete and correct. Any false or misleading information in, or in connection with this
certification, may be cause for disciplinary action against my license.
Signature on behalf of employer: ____________________________________________________________________________________________
(i.e., Director of Nursing or Physician.)
Date: _________ / __________ / __________
mo.
day
yr.
Print name: ____________________________________________________________________________________________________________
Title: _________________________________________________________________________________________________________________
New York State Profession: _______________________________________________________________________________________________
New York State Professional License Number: ______________________________________
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany,
NY 12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Nurse Form 5, Page 3 of 3, Rev. 8/15
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