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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.

Check what you are applying for:

Method number under which

you are applying for licensure

 Clinical Laboratory Technologist

92 $371

NYS License Number

Method __________________

 Certified Clinical Laboratory Technician

(You MUST complete this item or your

94 $263

application will be considered incomplete

and may delay your licensure.)

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

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

Mailing Address:

  Home or  Business

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

Line 1

Line 2

New York State DMV ID Number

(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

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

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

10. Are criminal charges pending against you in any court?

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?

Yes

 No

12. Are charges pending against you in any jurisdiction for any sort of professional misconduct?

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