Medicine Form 5a - Application For Limited Permit In Medicine For Applicants Who Have Applied For Licensure In New York State And All Limited Permit Renewals

The University of the State of New York

Department Use Only

Medicine Form 5A

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Division of Professional Licensing Services

Application for Limited Permit in Medicine for Applicants

Who Have Applied for Licensure in New York State and

ALL Limited Permit Renewals

$105

NOTE: This form is only for persons requesting a Limited Permit in Medicine who are also

applying for licensure in New York State. If you are not seeking licensure but still wish to

Approved

Rejected: ___________________________

apply for a Limited Permit, you must complete Form 5B.

Date: ______________________________

Applicants seeking to work under a limited permit in a general hospital. Section 405.4 of the

State Hospital Code (Title 10, New York Code, Rules and Regulations) established

additional requirements for practice by foreign medical school graduates with limited

Permit Number

permits. Please be sure you have read these requirements carefully before completing

the Limited Permit Application. Questions about this requirement may be directed to

Issued

the New York State Department of Health by calling 518-402-1003.

Expires

Social Security Number

(Leave this blank if you do not have a U.S. Social Security Number)

Telephone/E-Mail Address

Month

Birth Date

Day

Year

Daytime Phone

Print Full Name

Phone Number

Area Code

Last

E-Mail Address (Please print clearly)

First

Middle

Mailing Address (You must notify the Department promptly of any address or name changes.)

Line 1

I Am Applying For:

Line 2

Original Permit

Line 3

Renewal of Original Permit

City

Are you using FCVS to collect

State

Zip Code

your credentials?

Country/

Yes

Province

Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or

YES

misdemeanor) in any court?

YES

Are criminal charges pending against you in any court?

Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted

YES

surrender of, suspended, placed on probation, refused to renew a professional license or certificate held by you now or

previously, or ever fined, censured, reprimanded or otherwise disciplined you?

Are charges pending against you in any jurisdiction for any sort of professional misconduct?

YES

Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges

YES

or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition

of such measures?

NOTE: If you answer "Yes" to any questions numbered 8-12, submit a letter giving a complete detailed explanation. Include copies of any court records including a

Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. If the court can no longer provide documentation, you must

request, from the court, a letter stating why they cannot provide the documents.

COMPLETE THIS ITEM ONLY IF APPLYING FOR A RENEWAL OF ORIGINAL PERMIT

During the time period of the original permit, how many times did you attempt any part of the licensing examination sequence? ___________

What parts of the examination sequence did you attempt? _________________________________________________________________

Please provide the basis of your request for renewal of your original permit: ____________________________________________________

________________________________________________________________________________________________________________

Medicine Form 5A, Page 1 of 2, Rev. 6/16