Department Use Only
The University of the State of New York
Clinical Laboratory
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Technologist/Technician 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 appropriate licensure and first registration fee ($371
for clinical laboratory technologist, $263 for certified clinical laboratory technician) 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.
1.
Check what you are applying for:
Method number under which
1
you are applying for licensure
Clinical Laboratory Technologist
92 $371
ER
NYS License Number
Method __________________
Certified Clinical Laboratory Technician
(You MUST complete this item or your
94 $263
ER
application will be considered incomplete
and may delay your licensure.)
Date Issued
2.
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Initials
3
3.
Birth Date
Month
Day
Year
4
4.
Print Name
6
6.
Telephone/E-Mail Address
Last
Daytime phone
First
Home or Business
Middle
Licensee business address, phone and e-mail address are public information. Failure to
Area Code
Phone
indicate business or home on this form for each item will deem it public information.
E-mail Address
(please print clearly)
Home or Business
5.
Mailing Address:
Home or Business
5
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
6.
New York State DMV ID Number
7
(Driver or Non-Driver ID)
Line 3
City
(Leave this blank if you do not have a New
State
Zip Code
York State DMV ID Number)
Country/
Province
8
7.
Name as it appears on degree or other credentials (if different from above): _______________________________________________
9
Yes
No
8.
Have you previously applied for New York State licensure in any profession?
If “yes”, in what profession(s)? _______________________________________________________________
10
Yes
No
9.
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?
11
Yes
No
10. Are criminal charges pending against you in any court?
12
11. 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?
13
Yes
No
12. Are charges pending against you in any jurisdiction for any sort of professional misconduct?
14
13. Has any hospital or licensed facility or clinical laboratory restricted or terminated your professional training, employment, or privileges or
have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures?
Yes
No
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.
Clinical Laboratory Technologist/Technician Form 1, Page 1 of 4, Rev. 6/16