Cytotechnologist/certified Histological Technician - Application For Limited Permit - The University Of The State Of New York The State Education Department - 2009 Page 2
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2Section II: Clinical Laboratory Director’s Certification of Employment
A limited permit may be issued to an applicant who has met all requirements for licensure except the licensing examination. The permit is
valid for one year, and may not be extended, but may be renewed for one additional year for good cause as determined by the Department.
The applicant named in Section I is seeking a limited permit to practice as a cytotechnologist or certified histological technician in
New York State. Complete the information below to certify that the applicant will be employed by the facility or in the setting
described.
1.
Applicant's name: __________________________________________________________________________________________
2.
Name of Director of a Clinical Laboratory with a certificate of qualification issued by the NYS Department of Health:
_________________________________________________________________________________________________________
(print full name - no initials)
Facility name: ____________________________________________________________________________________________
Address: _________________________________________________________________________________________________
_________________________________________________________________________________________________________
3.
Telephone: ____________________________________________
Fax: _____________________________________________
4.
E-mail Address: ____________________________________________________________________________________________
5.
Title under which the applicant will be employed: __________________________________________________________________
Attestation of Clinical Laboratory Director
I declare that the statements made in the foregoing certification are true, complete and correct. Any false or misleading information in or
in connection with this certification may be the cause for denial of permit and licensure.
Clinical Laboratory Director's signature: ____________________________________________ Date _______ / _______ / _______
mo.
day
yr.
Print full name: ________________________________________________________________
Title: ________________________________________________________________________
Number of Certificate of Qualification
issued by NYS Department of Health: ______________________________________________
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY
12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Cytotechnologist/Certified Histological Technician Form 5, Page 2 of 2, Rev. 9/09
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