Looking for a New York State Legal Forms And Templates? Download it for free!

 

10.

11.

12.

 

Department Use Only

The University of the State of New York

Architect

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Form 1

Division of Professional Licensing Services

Application for Licensure

$347

Applicants Must Complete All Pages Of This Application In Ink

$377

All applicants for licensure must complete this form and submit it with the appropriate 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.

$587

You must sign and date the Affidavit on this form in the presence of a Notary Public.

NYS License Number

Social Security Number

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

Date Issued

Birth Date

Month

Day

Year

Print Name

Initials

Last

Telephone/E-Mail Address

First

Middle

Daytime phone

 Home or  Business

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

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

Area Code

Phone

Mailing Address:

 Home or Business

E-mail Address

(please print clearly)

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

 Home or  Business

Line 1

Line 2

Line 3

New York State DMV ID Number

City

(Driver or Non-Driver ID)

State

Zip Code

Country/

(Leave this blank if you do not have a New

Province

York State DMV ID Number)

I am applying (choose only one option):

to take the ARE concurrent with the IDP

for licensure via NCARB certification

for licensure based on 10 years of lawful practice as a

to take the ARE

for a limited permit (Section 7305)

Principal of my own firm (Section 7304.3). I have not

for licensure via endorsement

attempted an NCARB exam.

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 Do you now hold, or have ever held, a license or certificate to practice any profession in any jurisdiction?

(if so, list below and attach other pages as needed.)

____________________________________________________________________ __________________________ ___________________________________________

Profession

License number

Jurisdiction

____________________________________________________________________ __________________________ ___________________________________________

Profession

License number

Jurisdiction

Yes

No

11 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

Are criminal charges pending against you in any court?

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

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

NOTE: If you answer "Yes" to any questions numbered 11-14, 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.

Architecture Form 1, Page 1 of 4 Rev. 6/16