Cytotechnologist/certified Histological Technician - Application For Limited Permit - The University Of The State Of New York The State Education Department - 2009
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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 5
Application for Limited Permit
Applicant Instructions
1.
A limited permit authorizes practice as a cytotechnologist or certified histological technician under the
general supervision of 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 a
license as a cytotechnologist or certified histological technician in New York State. If you have not yet
filed an Application for Licensure (Form 1) and the licensure fee ($371 for cytotechnologist; $263 for
certified histological 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.
Permit Number
5.
The limited permit is valid for a period of one year. The permit may be renewed for one additional year if
the applicant 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,
Date Issued
made it impossible for the applicant to complete the examination required for licensure.
Section I: Applicant Information
Date Expires
1
Check what you are applying for:
Initials
93
$50
PR
F Cytotechnologist
91
$50
PR
F Certified Histological Technician
Telephone/E-Mail Address
6
2
Social Security Number
Daytime phone
(Leave this blank if you do not have a U.S. Social Security Number)
3
Birth Date
Month
Day
Year
Area Code
Phone
4
Print Name As It Appears On Your Application for Licensure (Form 1)
E-mail Address
(please print clearly)
Last
First
Middle
F If we may discuss your licensure
using this e-mail address, please
5
Mailing Address
(You must notify the Department promptly of any address or name changes.)
check this box.
Line 1
7
I am applying for:
Line 2
F
Original permit
Line 3
F
Renewal of Original Permit
(Attach justification)
City
F
Additional supervisor/employer
State
Zip Code
Country/
F
Change of supervisor/employer
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 licensure and may result in criminal
prosecution.
_________________________________________________________________________________ _______ / _______ / _______
Applicant’s Signature
mo.
day
yr.
Cytotechnologist/Certified Histological Technician Form 5, Page 1 of 2, Rev. 9/09
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