Marriage And Family Therapy - Application For Licensure - The University Of The State Of New York The State Education Department - 2016
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The University of the State of New York
Marriage and Family
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Therapist Form 1
Division of Professional Licensing Services
Application for Licensure
Applicants Must Complete All Pages of This Application In Ink
All applicants for licensure must complete this form and submit it with the $371 fee for licensure and first
registration directly to the Office of the Professions at the address at the end of this form. You must answer all
questions and provide all information requested unless otherwise indicated. Failure to complete all required
1
06 $371
ER
parts of the application will delay its review. You must sign and date the Affidavit on this form in the presence
of a Notary Public.
NYS License Number
2
Check One: Initial Licensure
License by Endorsement
1.
2.
Social Security Number
3
Date Issued
(Leave this blank if you do not have a U.S. Social Security Number)
4
3.
Birth Date
Month
Day
Year
Initials
5
4.
Print Name
Last
7
6.
Telephone/E-Mail Address
First
Daytime phone
Middle
Home or Business
Licensee business address, phone and e-mail address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
Area Code
Phone
E-mail Address
6
(please print clearly)
Mailing Address: Home or Business
5.
Home or Business
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
6.
New York State DMV ID Number
8
Line 3
(Driver or Non-Driver ID)
City
State
Zip Code
(Leave this blank if you do not have a New
Country/
York State DMV ID Number)
Province
9
7.
REASONABLE TESTING ACCOMMODATIONS FOR INDIVIDUALS WITH DISABILITIES. (Check if applicable)
I have been diagnosed as having a disability and require special testing accommodations and am submitting the Request for
Reasonable Testing Accommodations form to the address at the end of the form. I understand that I will not be able to test until I
submit the appropriate documentation and am approved to test with accommodations. (See Examination Section of the Licensing
Application Packet for information on obtaining the form.)
10
7.
Name as it appears on degree or other credentials (if different from above): ________________________________________________
11
Yes
No
9.
Have you previously applied for New York State licensure in any profession?
If “yes”, in what profession(s)? _______________________________________________________________
12
Yes
No
10. Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime
(felony or misdemeanor) in any court?
13
Yes
No
11. Are criminal charges pending against you in any court?
14
12. Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of,
suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined,
Yes
No
censured, reprimanded or otherwise disciplined you?
15
Yes
No
13. Are charges pending against you in any jurisdiction for any sort of professional misconduct?
14. Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever
16
Yes
No
voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures?
NOTE: If you answer "Yes" to any questions numbered 12-16, 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.
Marriage and Family Therapist Form 1, Page 1 of 4, Rev. 6/16
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