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The University of the State of New York

Department Use Only

Respiratory Therapy Form 5

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Division of Professional Licensing Services

Application for Limited Permit

APPLICANT INSTRUCTIONS

After submitting an application for licensure as a respiratory therapist or a respiratory therapy technician in New York

State, you may file an application for a limited permit to practice pending receipt of the license. A limited permit

authorizes practice as a respiratory therapist or respiratory therapy technician under supervision of a currently

registered, New York State licensed respiratory therapist or otherwise legally authorized physician along with the

endorsement of the employer. When applying for a limited permit, it is the applicant's responsibility to ensure that

the prospective supervisor fully completes the Certification of Supervision, Section II.

Complete Section I in ink and forward the form to your supervisor. Be sure to sign and date item 9. Limited permits

expire one year from the date of issue. You should be certain you are ready to begin practice when you apply for the

limited permit.

Submit this application with a check or money order for the required fee of $70 for the respiratory therapist or $50 for

respiratory therapy technician to the address at the end of this form. If you have not yet filed an Application for

Permit number

Licensure (Form 1) and the licensure fee, you must submit them with this form and the limited permit fee. The permit

application cannot be approved until all required documents have been received and approved. The applicant may

not begin practice until the limited permit is issued.

Date issued

If you change employment after a permit is issued, you must obtain a new permit by completing a new Form 5 with

your prospective supervisor, and returning it to the Office of the Professions. A fee is not required for a new permit

issued as a result of a change in employment.

Date expires

Section I: Applicant Information

Initials

Check what you are applying for:

$70

Respiratory Therapist (Permit)

Telephone/E-Mail Address

Respiratory Therapy Technician (Permit)

$50

Daytime Phone

Social Security Number

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

Area Code

Phone Number

Month

Birth Date

Day

Year

E-Mail Address (Please print clearly)

Print Name

Last

First

I am applying for:

Middle

Original permit

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

Additional employer/

supervisor

Line 1

Change of employer/

Line 2

supervisor

Line 3

City

State

Zip Code

Country/

Province

Are you licensed in another jurisdiction?

Yes



If "No," have you ever failed the NBRC Respiratory Therapist Registry examination?

Yes



If "No," have you ever failed the NBRC Respiratory Therapy Certification examination?

Yes

ATTESTATION

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

Respiratory Therapy Form 5, Page 1 of 2, Rev. 8/15

Respiratory Therapy Form 5 - Application For Limited Permit - New York The State Education Department

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