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The University of the State of New York

Creative Arts Therapist

THE STATE EDUCATION DEPARTMENT

Office of the Professions

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 parts of the application will delay its review.

Your signature on Form 1 must be notarized by a Notary Public. You must sign and date the Affidavit on this form in the

05 $371

presence of a Notary Public.

NYS License Number

Check One: Initial Licensure

License by Endorsement

Social Security Number

Date Issued

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

Birth Date

Month

Day

Year

Initials

Print Name

Last

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

Mailing Address:   Home or  Business

E-mail Address

(please print clearly)

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

  Home or  Business

Line 1

Line 2

Line 3

New York State DMV ID Number

(Driver or Non-Driver ID)

City

State

Zip Code

Country/

(Leave this blank if you do not have a New

York State DMV ID Number)

Province

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.)

Name as it appears on degree or other credentials (if different from above): ________________________________________________

Yes

 No

Have you previously applied for New York State licensure in any profession?

If “yes”, in what profession(s)? _______________________________________________________________

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?

Yes

 No

11. Are criminal charges pending against you in any court?

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?

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

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.

Creative Arts Therapist Form 1, Page 1 of 4, Rev. 6/16

Creative Arts Therapy - Application For Licensure - The University Of The State Of New York The State Education Department - 2016

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