Midwifery Form 5 - Application For Limited Permit (2016) printable pdf download

The University of the State of New York

Department Use Only

Midwife Form 5

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Division of Professional Licensing Services

Application for Limited Permit

APPLICANT INSTRUCTIONS

You may file an application for a limited permit with or after submitting an application for a license as a

midwife in New York State to practice pending receipt of the license. A limited permit authorizes practice as a

midwife under the supervision of a New York State licensed and currently registered midwife or physician.

Complete Section I in ink and have your supervisor complete Section II. Be sure to sign and date item 10. Once

limited permits are issued, they may not be adjusted. You should be certain you are ready to begin practice when

you apply for the limited permit. Submit this application and the required fee of $70 to the address at the end of this

form. If you have not yet filed an Application for Licensure (Form 1) and the $322 fee, you may submit them with this

form and the limited permit fee. The applicant may not begin practice until the limited permit is issued.

$70

If you change employment and/or supervising practitioner after a permit is issued, you must obtain a new permit.

The new permit is obtained by having the prospective employer and/or supervising practitioner complete a new

Permit number

Form 5. A fee is not required for a new permit issued as a result of a change in employer and/or supervising

practitioner.

NOTE: If you have more than one supervisor, a separate Form 5 must be completed by each. (Only one limited

Date issued

permit fee is required.)

SECTION I: APPLICANT INFORMATION

Date expires

Social Security Number

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

Initials

Month

Birth Date

Day

Year

Print Name

Telephone/E-Mail Address

Last

Daytime Phone

First

Middle

Area Code

Phone Number

E-Mail Address (Please print clearly)

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

Line 1

Line 2

I am applying for:

Line 3

Original permit

Additional supervisor/employer

City

(No fee required)

State

Zip Code

Change of supervisor/employer

(No fee required)

Country/

Province

PRACTICE LOCATION(S): (attach additional sheets if necessary)

Office/Facility Name: _______________________________________________________________________________________________________

Address: ________________________________________________________________________________________________________________

CITIZENSHIP/IMMIGRATION STATUS: Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses,

registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation, you must complete this section of this

form and check the appropriate box below which indicates your citizenship/immigration status.

I am:

 A.

A United States citizen or National.

 B.

An alien lawfully admitted for permanent residence in the United States.

 C.

An alien granted asylum under Section 208 of the Immigration and Nationality Act.

 D.

A refugee granted asylum under Section 207 of the Immigration and Nationality Act.

 E.

An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.

 F.

An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.

 G.

An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.

 H.

Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not required to have a Visa to enter the United

States: _______________________________________

 I.

I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar relief from deportation.

Please specify: _______________________________________

 J.

I do not reside in the United States.

If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship and Immigration Services (USCIS):

USCIS number: ___________________________________________

QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL LAW SHOULD BE DIRECTED TO THE U.S.

CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283, OR VISIT THEIR WEB SITE AT

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: _________________________________________________________________________ Date: ________________________

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