Request For Verification Of New York State Licensure Form

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The University of the State of New York
Request for Verification of New York State Licensure
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
A verification of licensure is an official letter that states whether an individual is licensed and currently
registered in New York State. It includes no additional information.
Instructions: Complete this form. Enclose payment for the $10 verification fee and submit this form with any
accompanying documents (such as other jurisdictions’ forms) to the Office of the Professions at the address
at the end of the form. Do not send cash. Make check or money order payable to the New York State
Department Use Only
Education Department. A separate Request for Verification of New York State Licensure form and fee must
be submitted for each verification requested.
Please Note: Payment submitted from outside the United States should be made by check or draft on a
United States bank and in United States currency; payments submitted in any other form will not be
accepted and will be returned.
Verification of New York State Licensure
$10
VL
1.
Licensee Information
Name: ____________________________________________________________________________________________________________________
Profession: ________________________________________________________________________________________________________________
(See list below)
License number: _____________________________________
Optional Information
Name Originally Licensed Under: _______________________________________________________________________________________________
2.
Name and Address to which verification is to be sent
Name: ____________________________________________________________________________________________________________________
Organization: ______________________________________________________________________________________________________________
Address: __________________________________________________________________________________________________________________
City: __________________________________________________________ State: ____________________ Zip Code: _________________________
Professions Licensed Under Title VIII of the Education Law
Acupuncturist
Landscape Architect
Physical Therapist
Architect
Land Surveyor
Physical Therapist Assistant
Athletic Trainer
Licensed Clinical Social Worker
Physician
Audiologist
Licensed Behavior Analyst
Podiatrist
Certified Clinical Laboratory Technician
Licensed Master Social Worker
Polysomnographic Technologist
Certified Behavior Analyst Assistant
Licensed Practical Nurse
Professional Engineer
Certified Dental Assistant
Marriage and Family Therapist
Psychoanalyst
Certified Histological Technician
Massage Therapist
Psychologist
Certified Public Accountant
Medical Physicist
Public Accountant
Certified Shorthand Reporter
Mental Health Counselor
Registered Physician Assistant
Chiropractor
Midwife
Registered Professional Nurse
Clinical Laboratory Technologist
Nurse Practitioner
Registered Specialist Assistant
Creative Arts Therapist
Occupational Therapist
Respiratory Therapist
Cytotechnologist
Occupational Therapy Assistant
Respiratory Therapy Technician
Dental Hygienist
Ophthalmic Dispenser
Speech-Language Pathologist
Dentist
Optometrist
Veterinarian
Dietitian/Nutritionist
Perfusionist
Veterinary Technician
Interior Designer
Pharmacist
Mail this form and fee to: New York State Education Department, Office of the Professions, Certification and Verification Unit, 89 Washington
Avenue, Albany, NY 12234-1000.
Request for Verification of New York State Licensure Form, April 2016

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