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Department Use Only

The University of the State of New York

Speech-Language Pathology

THE STATE EDUCATION DEPARTMENT

Office of the Professions

& Audiology Form 1

Division of Professional Licensing Services

Application for Licensure

Applicants Must Complete All Pages of This Application In Ink

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

registration 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 sign and date the Affidavit on this form in the presence

of a Notary Public.

Check what you are applying for:

NYS License Number

 Please check here if you are

 Speech-Language Pathologist

58 $294

applying for licensure by

endorsement.

 Audiologist

57 $294

Date Issued

Social Security Number

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

Initials

Birth Date

Month

Day

Year

Print Name

Telephone/E-Mail Address

Last

Daytime phone

First

  Home or  Business

Middle

Area Code

Phone

Licensee business address, phone and e-mail address are public information. Failure to

E-mail Address

(please print clearly)

indicate business or home on this form for each item will deem it public information.

  Home or  Business

Mailing Address:

  Home or  Business

(You must notify the Department promptly of any address or name changes.)

Line 1

New York State DMV ID Number

Line 2

(Driver or Non-Driver ID)

Line 3

City

(Leave this blank if you do not have a New

York State DMV ID Number)

State

Zip Code

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

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 10-14, 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.

Speech-Language Pathology & Audiology Form 1, Page 1 of 4, Rev. 6/16

Speech-Language Pathology And Audiology - Application For Licensure - The University Of The State Of New York The State Education Department - 2016

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