Form 3 - Verification Of Out-Of-State Licensure, Registration And/or Examination Form
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1
2NOTE: Licensure or registration in
Professional Engineering
The University of the State of New York
another
jurisdiction
is
not
a
THE STATE EDUCATION DEPARTMENT
Form 3
requirement for licensure in New
Office of the Professions
York.
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
VERIFICATION OF OUT-OF-STATE LICENSURE,
REGISTRATION AND/OR EXAMINATION
(Must be filed by all applicants who are or have been licensed in another jurisdiction
or want to verify passing parts of the licensing examination in another state)
APPLICANT INSTRUCTIONS
Complete Section I. Be sure to sign and date item 8.
A. Verification of Examination(s) for Licensure
•
If you are applying for admission to the Principles and Practice Examination and have passed the Fundamentals Examination in another
jurisdiction, send this form to that jurisdiction and request that they complete Section II and forward directly to the address at the end of this
form*.
•
If you are applying for licensure on the basis of endorsement of your examination grades, send this form to the jurisdiction(s) where you took
and passed the licensing examination(s) and to the jurisdiction where you are currently licensed and registered and ask that they complete
Section II and send directly to the address at the end of this form*.
B. Verification of Licensure/Registration for a Limited Permit.
•
If you are applying for a Limited Permit, complete Section I and send this form to the jurisdiction where you currently reside and are legally
qualified to practice and ask they complete Section II and send directly to the address at the end of this form*.
* Be sure to include any fee required by the licensing authority.
SECTION I: APPLICANT INFORMATION
Social Security Number:
3
1
Print Full Name Exactly As It Appears On Your Licensure Application (Form 1)
Last
(Leave this blank if you do not have a U.S.
First
social security number)
Middle
Birth Date
4
2
Mailing Address
Line 1
mo .
day
yr.
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
I am applying for: (check one)
NYS license
Limited Permit
6
If licensed by examination in the United States, give state or territory: _____________________________________________________________
7
Print or type your name in the exact form in which the engineering license was issued:
____________________________________________________________________________________________________________________
8
To the Engineering State Board of: _________________________________________________________________________
Check Appropriate boxes:
I hereby make application for the transfer of examination grades and related information.
I am a licensed Engineer of your state. License number: _______________________
Date issued: _____ / _____ / _____
mo .
day
yr.
I request and give permission to the licensing authority above to complete the information on this form and send any documentation requested,
including that requested on this form, to the New York State Education Department.
Signature of applicant: ______________________________________________________ Date ______ / ______ / ______
mo .
day
yr.
Professional Engineering Form 3, Page 1 of 2, June 2004
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