Licensed Master/social Worker - Application For Licensure - The University Of The State Of New York The State Education Department - 2016

Department Use Only

The University of the State of New York

Licensed Master

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Social Worker Form 1

Division of Professional Licensing Services

Application for Licensure

Applicants Must Complete All Pages of This Application In Ink

72 $294

All applicants for licensure must complete this form and submit it with the $294 licensure and first registration fee 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. You must

NYS License Number

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

Social Security Number

Date Issued

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

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

(Driver or Non-Driver ID)

Line 3

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

Have you passed the Association of Social Worker Boards (ASWB) masters examination?

Note: New York State will not accept an examination given under non-standard conditions such as the use of a dictionary or extra time for applicants whose primary language

is other than English. A candidate may be required to retake the examination under standard conditions.

If “yes”, on what date(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 11-15, 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.

Licensed Master Social Worker Form 1, page 1 of 4, Rev. 6/16