Polysomnographic Technologist Form 1 - Application For Authorization printable pdf download

Department Use Only

The University of the State of New York

Polysomnographic

THE STATE EDUCATION DEPARTMENT

Technologist Form 1

Office of the Professions

Division of Professional Licensing Services

Application for Authorization

Applicants Must Complete All Pages of This Application In Ink

All applicants for authorization must complete this form and submit it with the $600 fee for

authorization 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.

26 $600

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

Affidavit on this form in the presence of a Notary Public.

NYS License Number

Social Security Number

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

Date Issued

Birth Date

Month

Day

Year

Initials

Print Name

Last

Telephone/E-Mail Address

First

Daytime phone

  Home or  Business

Middle

Licensee business address, phone and e-mail address are public information. Failure to

Area Code

Phone

indicate business or home on this form for each item will deem it public information.

E-mail Address

(please print clearly)

Mailing Address:   Home or  Business

  Home or  Business

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

Line 1

Line 2

New York State DMV ID Number

Line 3

(Driver or Non-Driver ID)

City

(Leave this blank if you do not have a New

State

Zip Code

York State DMV ID Number)

Country/

Province

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 10-14, 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.

Polysomnographic Technologist Form 1, Page 1 of 4, Rev. 6/16

Polysomnographic Technologist Form 1 - Application For Authorization

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