Polysomnographic Technologist Form 5 - Application For Limited Permit - New York The State Education Department
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1
2Department Use Only
The University of the State of New York
Polysomnographic
THE STATE EDUCATION DEPARTMENT
Technologist Form 5
Office of the Professions
Division of Professional Licensing Services
Application for Limited Permit
Applicants Must Complete All Pages of This Application In Ink
Applicant Instructions
1.
A limited permit authorizes practice as a polysomnographic technologist under the direction and
supervision of a licensed physician and under the direct and immediate supervision of a currently
registered New York State licensed health care provider whose scope of practice includes all of the tasks
he or she will be supervising. You must meet all requirements for authorization as a polysomnographic
technologist except the licensing examination. Complete Section I. Be sure to sign and date item 9. It
26
$70
PR
1
is your responsibility to ensure that the prospective supervisor fully completes Section II.
2.
You may apply for a limited permit either at the same time as or after submitting an application for
Permit Number
authorization as a polysomnographic technologist in New York State. If you have not yet filed a
Application for Authorization (Form 1) and the $600 fee for authorization and first registration, you must
submit them with this form and the limited permit fee.
Date Issued
3.
Submit this application and the $70 limited permit fee to the Office of the Professions at the address at
the end of this form.
4.
Permits cannot be issued until all required documents have been received and approved. You
may not begin practice until a limited permit has been issued.
Date Expires
5.
If you change supervisors or have additional supervisors after a permit is issued, you must obtain a
re-issued permit. Complete a new Form 5 with each prospective supervisor, and return it to the Office of
the Professions. A new fee is not required for a permit issued as a result of a change in supervisor.
Initials
Limited permits expire one year from the date of issue and may be renewed for one additional year.
IMPORTANT NOTE: If the physician providing direction and supervision is not also the individual
providing direct and immediate supervision, you will need to submit a separate Form 5 for each.
6
6.
Telephone/E-Mail Address
2.
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Daytime phone
3.
3
Birth Date
Month
Day
Year
Area Code
Phone
4
4.
Print Name
E-mail Address
(please print clearly)
Last
First
Middle
7
I am applying for
5.
Mailing Address
5
(You must notify the Department promptly of any address or name changes.)
Original permit
Line 1
Additional supervisor/employer
Line 2
Change of supervisor/employer
Line 3
Renewal Permit
City
State
Zip Code
Country/
Province
8
8.
Name of employer: _____________________________________________________________________________________________
9.
Attestation
9
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
mo.
day
yr.
Polysomnographic Technologist Form 5, Page 1 of 2, August 2012
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