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The University of the State of New York

Department Use Only

Ophthalmic Dispensing

THE STATE EDUCATION DEPARTMENT

Form 5

Application for Limited Permit

APPLICANT INSTRUCTIONS

After submitting an application for licensure as a ophthalmic dispenser in New York State, you may file an

application for a limited permit to practice pending receipt of the license. A limited permit in Contact Lens Dispensing

can only be issued simultaneous with the issuance of a limited permit in Ophthalmic Dispensing or to an applicant

who is already licensed as an ophthalmic dispenser.



An ophthalmic dispenser permittee may practice only under the supervision of a New York State licensed,

currently registered physician, optometrist or ophthalmic dispenser. The supervisor must be on-site.



A contact lens permittee may practice only under the supervision of a New York State licensed, currently

OD PERMIT NO.___________________________

registered physician, optometrist or ophthalmic dispenser certified in contact lens dispensing. The supervisor

ISSUED __________________________________

must be on-site.

When applying for a limited permit, it is your responsibility to ensure that your prospective supervisor fully completes

the Certification of Supervision, Section II.

EXPIRES 2 YEARS FROM DATE OF ISSUE

Complete Section I and forward the form to your employer. Be sure to sign and date item 9. Limited permits expire

OD 1 YEAR RENEWAL

two years from the date of issue. You should be certain you are ready to begin practice when you apply for the

limited permit.

ISSUED __________________________________

Limited Permits are issued for two years and expire when the applicants who pass the exam receive their license or

EXPIRES _________________________________

ten (10) days after applicants are notified that they were unsuccessful on the practical licensing examination.

Limited permits can be renewed for one additional year if the applicant did not fail the exam or was not denied

licensure. An additional fee of $35 is required for a renewal.

CL PERMIT NO.____________________________

Submit this application with a check or money order for the required fee of $35 made payable to the New York State

Education Department, to the Office of the Professions at the address at the end of this form. If you have not already

ISSUED __________________________________

done so, you must submit an Application for Licensure (Form 1) and the licensure fee with this form and the limited

permit fee. The permit application cannot be approved until all required documents have been received and

EXPIRES 2 YEARS FROM DATE OF ISSUE

approved. You may not begin practice until the limited permit is issued.

If you change or add employers or supervisors after the permit is issued, you must obtain a new permit. You may

CL 1 YEAR RENEWAL

obtain a new permit by completing, with your prospective employer, a new Form 5 and returning it to the Office of

ISSUED __________________________________

the Professions. A fee is not required for a new permit issued as a result of a change in employment.

EXPIRES _________________________________

SECTION I: APPLICANT INFORMATION

Check what you are applying for:

Initials

$35

Ophthalmic Dispensing (Limited Permit)

Telephone/E-Mail Address

$35

Contact Lens Dispensing (Limited Permit)

Social Security Number

Daytime Phone

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

Birth Date

Month

Day

Year

Area Code

Phone Number

Print Name

E-Mail Address (Please print clearly)

Last

First

Middle

I am applying for:

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

Line 1

Original permit

Additional/change of supervisor

Line 2

(No fee required)

Line 3

Additional/change of employer

(No fee required)

City

Renewal

State

Zip Code

Country/

Province

Name of employer: _______________________________________________________________________________________________________

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.

_______________________________________________________________________________________

________________________

Signature of applicant

Date

Ophthalmic Dispensing Form 5, Page 1 of 2, Rev. 8/15

Ophthalmic Dispensing Form 5 - Application For Limited Permit - New York The State Education Department

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