Psychology Form 5a - Application For Limited Permit - New York The State Education Department

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The University of the State of New York
Department Use Only
Psychologist Form 5A
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
Application for Limited Permit
For Persons Gaining Experience for Licensure
APPLICANT INSTRUCTIONS
To be eligible to practice psychology while gaining professional experience in New York State under a
limited permit, you must:
a.
Have completed all doctoral degree requirements, including your doctoral dissertation.
b.
Meet all other licensure requirements except the examination and professional experience.
If you meet these eligibility requirements, then:
1
68
$70
PR
1.
Submit an application for a limited permit (Form 5A) to practice to gain the required amount of
professional experience while under the supervision of a currently registered, New York State
Permit Number
licensed psychologist. A limited permit authorizes practice as a psychologist for one year and may be
renewed for an aggregate of three years. A one year extension may be granted for good cause as
determined by the Department.
Date Issued
2.
Complete Section I in ink, be sure to sign and date item 9, and then give this form to your supervisor
to complete Section III.
3.
Send this application with a check or money order for the required fee of $70 to the address at the
Date Expires
end of this form. The permit application cannot be approved until all required documents have been
received and approved. You may not begin practice as a psychologist until the limited permit is
issued.
Initials
If you need to request a renewal you must submit a new Application for Limited Permit (Form 5A) and a
Report of Professional Experience (Form 4) for the time that you have been gaining experience. Your
experience will be reviewed before the renewal may be issued.
6
Telephone/E-Mail Address
SECTION I: APPLICANT INFORMATION
Daytime Phone
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Area Code
Phone Number
E-Mail Address (Please print clearly)
3
Month
Birth Date
Day
Year
4
Print Name
7
I Am Applying For:
Last
Original Permit
First
Change in:
Middle
Employer
Supervisor
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
Additional:
Line 1
Employer
Line 2
Supervisor
Line 3
Renewal – One year
City
One Year Extension
State
Zip Code
Country/
Province
8
Employers Name: ________________________________________________________________________________________________________
9
Affidavit: 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.
Psychologist Form 5A, Page 1 of 2, Rev. 8/15

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