Psychology Form 5a - Application For Limited Permit - New York The State Education Department Page 2
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1
2SECTION II: INSTRUCTIONS TO THE SUPERVISING PSYCHOLOGIST
1.
By completing the information below, the supervisor is certifying that the permittee named in Section I will be under the
supervision of a New York State licensed and currently registered psychologist for the duration of the permit and the
employer agrees to abide by the conditions stipulated on the permit.
2.
A limited permit shall expire one year from the date of issuance. The permit may be renewed one year at a time for an
aggregate of three years. The permit may then be extended for one additional year for good cause as determined by the
department
The applicant may not practice psychology until the limited permit is issued.
3.
SECTION III: CERTIFICATION OF SUPERVISING PSYCHOLOGIST
1.
Name of Supervising Psychologist: _______________________________________________________________________
2.
License number: ____________________________________
3.
Office address: ______________________________________________________________________________________
Street
______________________________________________________________________________________
City
State
Zip Code
4.
Telephone: _________________________________________
Fax: _______________________________________________
E-mail: _____________________________________________
ATTESTATION
I declare and affirm that the statements made in the foregoing certification are true, complete and correct. Any false or misleading information in, or in
connection with, this certification may be cause for denial of permit and licensure and may result in criminal prosecution.
______________________________________________________________________________________
______________________________
Signature
Date
_____________________________________________________________________________________
_
Title
_____________________________________________________________________________________
_
Print name
_____________________________________________________________________________________
_
Address
_________________________________________ ___________________________________________
_
Telephone
Fax
______________________________________________________________________________________
E-mail
RETURN DIRECTLY
New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201.
TO:
Psychologist Form 5A, Page 2 of 2, Rev. 8/15
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