Cytotechnologist/certified Histological Technician - Application For Licensure - The University Of The State Of New York The State Education Department - 2016
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Department Use Only
The University of the State of New York
Cytotechnologist
THE STATE EDUCATION DEPARTMENT
Certified Histological Technician
Office of the Professions
Division of Professional Licensing Services
Form 1
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 fee for licensure and
first registration ($371 for cytotechnologists, $263 for certified histological technicians) 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.
NYS License Number
1
Check what you are applying for:
93 $371
ER
Cytotechnologist
Date Issued
91 $263
ER
Certified Histological Technician
Initials
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
6
Telephone/E-Mail Address
3
Birth Date
Month
Day
Year
4
Daytime phone
Print Name
Home or Business
Last
First
Area Code
Phone
Middle
E-mail Address
(please print clearly)
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.
5
Mailing Address:
Home or Business
(You must notify the Department promptly of any address or name changes.)
New York State DMV ID Number
7
(Driver or Non-Driver ID)
Line 1
Line 2
(Leave this blank if you do not have a New
York State DMV ID Number)
Line 3
City
State
Zip Code
Country/
Province
8
Name as it appears on degree or other credentials (if different from above): _______________________________________________
9
Yes
No
Have you previously applied for New York State licensure in any profession?
If “yes”, in what profession(s)? _______________________________________________________________
Yes
No
10 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
11 Are criminal charges pending against you in any court?
12 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?
13
Cytotechnologist/Certified Histological Technician Form 1, Page 1 of 4, Rev. 8/16
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