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

ADVERTISEMENT

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
60
$105
PR
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
1
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
5
Telephone/E-Mail Address
2
Month
Birth Date
Day
Year
Daytime Phone
3
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.)
4
Line 1
6
I Am Applying For:
Line 2
Original Permit
Line 3
Renewal of Original Permit
City
7
Are you using FCVS to collect
State
Zip Code
your credentials?
Country/
Yes
No
Province
8
Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or
YES
NO
misdemeanor) in any court?
YES
9
NO
Are criminal charges pending against you in any court?
10
Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted
YES
NO
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?
11
Are charges pending against you in any jurisdiction for any sort of professional misconduct?
YES
NO
12
Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges
YES
NO
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.
13
COMPLETE THIS ITEM ONLY IF APPLYING FOR A RENEWAL OF ORIGINAL PERMIT
A.
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? _________________________________________________________________
B.
Please provide the basis of your request for renewal of your original permit: ____________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Medicine Form 5A, Page 1 of 2, Rev. 6/16

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2