Clinical Laboratory Technologist/technician Form 5 - Application For Limited Permit
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Department Use Only
The University of the State of New York
Clinical Laboratory
THE STATE EDUCATION DEPARTMENT
Technologist/Technician
Office of the Professions
Division of Professional Licensing Services
Form 5
Application for Limited Permit
Applicant Instructions
1.
A limited permit authorizes practice as a clinical laboratory technologist or a certified clinical laboratory technician under
the general supervision of a Clinical Laboratory Director. Complete Section I. Be sure to sign and date item 9. It is your
responsibility to ensure that your employer fully completes Section II.
2.
You may apply for a limited permit either at the same time as or after submitting an application for licensure as a clinical
laboratory technologist or as a certified clinical laboratory technician in New York State. If you have not yet filed an
Application for Licensure (Form 1) and the appropriate fee ($371 for clinical laboratory technologist, $263 for certified
clinical laboratory technician), you must submit them with this form and the limited permit fee. Permits cannot be
issued until all required documentation has been received and approved.
3.
Submit this application and the $50 fee to the Office of the Professions at the address at the end of this form.
4.
If you change supervisors or have additional supervisors after a permit is issued, you must obtain an amended permit.
Complete a new Form 5 with each prospective supervisor, and return it to the Office of the Professions. A new fee is not
required for a permit issued as a result of a change in supervisor/employer.
5.
The limited permit is valid for a period of one year. The permit may be renewed for one additional year if the applicant
Permit Number
can document good cause, such as a specific physical or mental disability certified by an appropriate health care
professional or other good cause which, in the judgement of the Department, made it impossible for the applicant to
complete the examination required for licensure.
Date Issued
Section I: Applicant Information
Check what you are applying for:
Date Expires
1
F Clinical Laboratory Technologist Limited Permit
92
$50
PR
Initials
F Certified Clinical Laboratory Technician Limited Permit
94
$50
PR
Social Security Number
Telephone/E-Mail Address
2
6
(Leave this blank if you do not have a U.S. Social Security Number)
Daytime Phone
Birth Date
Month
Day
Year
3
Print Name As It Appears On Your Application for Certification/Licensure (Form 1)
Area Code
Phone Number
4
Last
E-mail Address
(please print clearly)
First
Middle
5
Mailing Address
I am applying for:
(You must notify the Department promptly of any address or name changes.)
7
F
Original permit
Line 1
F
Renewal of Original Permit
Line 2
(Attach justification)
Line 3
F
Additional supervisor/employer
City
F
Change of supervisor/employer
State
Zip Code
Country/
Province
8
Name of prospective supervising Clinical Laboratory Director: ___________________________________________________________
9
Attestation
I declare and affirm that the statements made in the foregoing application are true, complete and correct. Any false or misleading
information in, or in connection with, my application may be cause for denial of permit and certification/licensure and may result in
criminal prosecution.
_________________________________________________________________________________ _______ / _______ / _______
Applicant’s Signature
mo.
day
yr.
Clinical Laboratory Technologist/Technician Form 5, Page 1 of 2, Rev. 9/09
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