Form 5 - Application For Limited Permit
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1
2Department Use Only
The University of the State of New York
Licensed Master
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Social Worker Form 5
Division of Professional Licensing Services
Application for Limited Permit
Applicant Instructions
72
$70
PR
1
1.
A limited permit authorizes practice as a licensed master social worker under the general supervision of
an LMSW or an LCSW. Complete Section I. Be sure to sign and date item 9. It is your responsibility to
Permit Number
ensure that your 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 a
license as a LMSW in New York State. If you have not yet filed an Application for Licensure (Form 1) and
Date Issued
the licensure fee ($294), you must submit them with this form and the limited permit fee.
3.
Submit this application and the $70 fee to the Office of the Professions at the address at the end of this
form.
Date Expires
4.
Permits cannot be issued until all required documents have been received and approved.
5.
If you change supervisors or have additional supervisors after a permit is issued, you must obtain a re-
Initials
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.
6
6.
Telephone/E-Mail Address
Section I: Applicant Information
2
Daytime phone
2.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
3
Area Code
Phone
3.
Birth Date
Month
Day
Year
4
E-mail Address
4.
Print Name
(please print clearly)
Last
First
Middle
5
7
5.
Mailing Address
(You must notify the Department promptly of any address or name changes.)
I am applying for
Original permit
Line 1
Additional supervisor
Line 2
Additional employer
Line 3
Change of supervisor
City
Change of employer
State
Zip Code
Country/
Province
8
8.
Name of employer: _____________________________________________________________________________________________
9
9.
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.
_________________________________________________________________________________ _______ / _______ / _______
Applicant’s Signature
mo.
day
yr.
Licensed Master Social Worker Form 5, page 1 of 2, Rev. 8/15
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