Form 5 - Application For Limited Permit - The State Education Department printable pdf download

The University of the State of New York

Department Use Only

Nurse Form 5

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Division of Professional Licensing Services

Application for Limited Permit

APPLICANT INSTRUCTIONS

A limited permit authorizes practice as a nurse under the immediate and personal supervision of a New York State

licensed, currently registered, registered professional nurse and with the endorsement of the employer. Complete

Section I. Be sure to sign and date item 11 on page 2. It is your responsibility to ensure that your prospective

employer fully completes Section II. Note: Once a limited permit is issued, it may not be adjusted. You should be

certain you are ready to begin practice when you apply for the limited permit. You may not begin practice until your

Date Approved/Rejected

limited permit is issued unless you meet the practice exemption detailed in the Instructions to the Employer in

Section II of this form.

You may apply for a limited permit either at the same time as or after submitting an Application for Licensure (Form

1). If you have not yet filed a Form 1 and the licensure fee ($143), you must submit them with this form and the

Permit number

limited permit fee. Permits cannot be issued until all required documentation has been received and

approved.

Submit this application and the $35 fee to the Office of the Professions, at the address at the end of this form.

Date issued

If you change employment after your permit is issued, you must obtain a new permit by completing a new Form 5

with your prospective employer. A new fee is not required for a permit issued as a result of a change in employment.

Section I: Applicant Information

Date expires

Check what you are applying for:

Initials

$35

Registered Professional Nurse (Limited Permit)

$35

Licensed Practical Nurse (Limited Permit)

Telephone/E-Mail Address

Social Security Number

Daytime Phone

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

Birth Date

Month

Day

Year

Area Code

Phone Number

Print Name

E-Mail Address (Please print clearly)

Last

First

Middle

I am applying for:

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



Original permit

Line 1



Additional supervisor/

employer

Line 2



Change of supervisor/

Line 3

employer

City

State

Zip Code

Country/

Province



Are you licensed as a nurse in another jurisdiction?

Yes

If no, have you ever failed the RN licensing examination?

Yes*



If no, have you ever failed the PN licensing examination?

Yes**

*You are not eligible for an RN permit if you have ever taken the NCLEX-RN examination.

**You are not eligible for an LPN permit if you have ever taken the NCLEX-PN examination.



FOREIGN EDUCATED NURSES ONLY Have you successfully completed: (Check one)

CGFNS

CNATS

Date CGFNS Qualifying Examination written _______ / _______ / _______

*CGFNS Certificate No. ___________________________________

Date CNATS Examination written _______ / _______ / _______

CNATS Exam Score ______________________________________

* CGFNS must submit this certificate directly to the Office of the Professions.

Name and address of nursing school attended ___________________________________________________________________________________

____________________________________________________________________________ Date degree completed _______ / _______ / _______

mo.

day

yr.

Nurse Form 5, Page 1 of 3, Rev. 8/15

Form 5 - Application For Limited Permit - The State Education Department

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