Request For Certification Of New York State Licensure Form

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The University of the State of New York
Request for Certification of New York State Licensure
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
A certification of licensure is an official statement of the basis of licensure in New York State, including such
items as professional school attended and professional examination results which may be required for
licensure in another jurisdiction. This statement will only be issued at the request of the licensee.
Instructions: Complete this form, be sure to sign and date item 3. Enclose payment for the $20 certification
fee and submit this form with any accompanying documents (such as other jurisdictions’ forms) to the Office
Department Use Only
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 Education Department. A separate Request for Certification of New York
State Licensure form and fee must be submitted for each certification 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.
$20
CL
Certification of New York State Licensure
1.
Licensee Information
Name: ____________________________________________________________________________________________________________________
Address: __________________________________________________________________________________________________________________
City: __________________________________________________________ State: ____________________ Zip Code: _________________________
Daytime telephone number: ____________________________ E-mail: ________________________________________________________________
Profession: ______________________________________________________________________ License number: ___________________________
(See list below)
Name Originally Licensed Under: _______________________________________________________________________________________________
Social Security Number:
(Leave this blank if you do not have a U.S. Social Security Number)
Birth Date:
Month
Day
Year
2.
Name and Address to which certification is to be sent
Name: ____________________________________________________________________________________________________________________
Organization: ______________________________________________________________________________________________________________
Address: __________________________________________________________________________________________________________________
City: __________________________________________________________ State: ____________________ Zip Code: _________________________
3.
Licensee Signature
Signature: _________________________________________________________________________ Date: ___________________________________
Print name: ________________________________________________________________________
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 Certification of New York State Licensure Form, March 2016

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