Acupuncture Form 5 - Application For Limited Permit
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1
2The University of the State of New York
Department Use Only
Acupuncture Form 5
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
Application for Limited Permit
APPLICANT INSTRUCTIONS
You may file an application for a limited permit with or after submitting an application for licensure as a
acupuncturist in New York State. The limited permit allows you to practice acupuncture for a period of one
year pending completion of your examination requirement. A permittee can practice acupuncture only
under the on-site supervision of a New York State licensed and currently registered acupuncturist or a New
York State licensed and currently registered physician or dentist certified to practice acupuncture. No
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25
$70
PR
practitioner may supervise more than one permittee. Legal practice sites include a public hospital, an
incorporated hospital or clinic, a licensed proprietary hospital, a licensed nursing home, a public health
Permit Number
agency, the office of a licensed or certified acupuncturist or in the civil service of the federal or state
government. The limited permit is valid for a period of one year and may be renewed for up to one
additional year with approval of the Department.
Date Issued
Complete Section I of this form. Your employer must complete Section II. Send this completed form with a
check or money order payable to the New York State Education Department at the address at the end of
this form. If you have not yet filed an Application for Licensure and First Registration (Form 1) and the
Date Expires
$788 fee, you may submit them with this form and the limited permit fee. Your limited permit can not be
issued until we receive and approve all required documentation.
6
Telephone/E-Mail Address
SECTION I: APPLICANT INFORMATION
Daytime Phone
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Area Code
Phone Number
E-Mail Address (Please print clearly)
3
Birth Date
Month
Day
Year
4
Print Name Exactly As It Appears On Your Licensure Application (Form 1)
7
I Am Applying For:
Last
Original Permit
First
Renewal of Original Permit
Middle
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
Acupuncture Form 5, Page 1 of 2, Rev. 9/09
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