Occupational Therapy Form 5 - Application For A Limited Permit - New York The State Education Department

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The University of the State of New York
Department Use Only
Occupational Therapy Form 5
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
Application for Limited Permit
Applicant Instructions
1.
You may file an application for a limited permit to practice pending receipt of the license with or after
submitting an Application for Licensure/Authorization (Form 1 and fee) as an occupational therapist or
occupational therapy assistant in New York State. A limited permit authorizes practice as an occupational
therapist or occupational therapy assistant under the supervision of a New York State licensed, currently registered
occupational therapist or physician with the endorsement of the employer. Be sure that your prospective employer
and supervisor fully complete Section II, Employer Certification of Supervision.
Permit Number
2.
Complete Section I in ink. Be sure to sign and date item 9. Note: Once limited permits are issued, the starting date
may not be adjusted. You should be certain you are ready to begin practice when you apply for the limited permit.
3.
Submit this application and the $70 limited permit fee to the Office of the Professions at the address at the end of
Date Issued
the form. If you have not yet filed an Application for Licensure (Form 1) with the appropriate fee, you must submit
them with this form. You may not begin practice until your limited permit is issued. A limited permit is valid for one
year and may be renewed for an additional year upon submission of an explanation satisfactory to the Department
as to why you failed to become licensed within the year of the original permit.
Date Expires
4.
If you change employment or supervisor after a permit is issued, you must obtain a new permit and, with each
prospective employer/supervisor, complete a new Form 5 and return it to the Office of the Professions. A new fee is
not required for a permit issued as a result of a change in employment.
Initials
Section I: Applicant Information
1
Check what you are applying for:
6
Telephone/E-Mail Address
63
$70
PR
Occupational Therapist
Daytime Phone
64
$70
PR
Occupational Therapy Assistant
2
Social Security Number
Area Code
Phone Number
(Leave this blank if you do not have a U.S. Social Security Number)
E-Mail Address (Please print clearly)
3
Month
Birth Date
Day
Year
4
Print Name
Last
7
I Am Applying For:
First
Original Permit
Middle
Renewal of Original Permit
(attach explanation)
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
Change in:
Line 1
Employer
Line 2
Supervisor
Line 3
Additional:
City
Employer
State
Zip Code
Supervisor
Country/
Province
8
Name as it appears on diploma if different from above: ____________________________________________________________________________
9
Attestation
Notice to Applicants Regarding Limited Permit Authorizing Practice as an Occupational Therapist or Occupational Therapy Assistant: The
law authorizes a permittee to practice under the supervision of a licensed and currently registered occupational therapist or physician in a public,
voluntary, or proprietary hospital or health care agency, or in a preschool or elementary school as a related service for a handicapped child.
I declare and affirm that the statements made in the foregoing application are true, complete and correct. Any false or misleading information in, or in
connection with, my application may be cause for denial of permit and licensure and may result in criminal prosecution.
_____________________________________________________________________________________________
_______ / _______ / _______
Applicant’s signature
mo.
day
yr.
Occupational Therapy Form 5, Page 1 of 2, Rev. 8/15

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