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The University of the State of New York

Department Use Only

Occupational Therapy Form 5

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Division of Professional Licensing Services

Application for Limited Permit

Applicant Instructions

You may file an application for a limited permit to practice pending receipt of the license with or after

submitting an Application for Licensure/Authorization (Form 1 and fee) as an occupational therapist or

occupational therapy assistant in New York State. A limited permit authorizes practice as an occupational

therapist or occupational therapy assistant under the supervision of a New York State licensed, currently registered

occupational therapist or physician with the endorsement of the employer. Be sure that your prospective employer

and supervisor fully complete Section II, Employer Certification of Supervision.

Permit Number

Complete Section I in ink. Be sure to sign and date item 9. Note: Once limited permits are issued, the starting date

may not be adjusted. You should be certain you are ready to begin practice when you apply for the limited permit.

Submit this application and the $70 limited permit fee to the Office of the Professions at the address at the end of

Date Issued

the form. If you have not yet filed an Application for Licensure (Form 1) with the appropriate fee, you must submit

them with this form. You may not begin practice until your limited permit is issued. A limited permit is valid for one

year and may be renewed for an additional year upon submission of an explanation satisfactory to the Department

as to why you failed to become licensed within the year of the original permit.

Date Expires

If you change employment or supervisor after a permit is issued, you must obtain a new permit and, with each

prospective employer/supervisor, complete a new Form 5 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 employment.

Initials

Section I: Applicant Information

Check what you are applying for:

Telephone/E-Mail Address

$70

Occupational Therapist

Daytime Phone

$70

Occupational Therapy Assistant

Social Security Number

Area Code

Phone Number

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

E-Mail Address (Please print clearly)

Month

Birth Date

Day

Year

Print Name

Last

I Am Applying For:

First

Original Permit

Middle

Renewal of Original Permit

(attach explanation)

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

Change in:

Line 1

Employer

Line 2

Supervisor

Line 3

Additional:

City

Employer

State

Zip Code

Supervisor

Country/

Province

Name as it appears on diploma if different from above: ____________________________________________________________________________

Attestation

Notice to Applicants Regarding Limited Permit Authorizing Practice as an Occupational Therapist or Occupational Therapy Assistant: The

law authorizes a permittee to practice under the supervision of a licensed and currently registered occupational therapist or physician in a public,

voluntary, or proprietary hospital or health care agency, or in a preschool or elementary school as a related service for a handicapped child.

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.

Occupational Therapy Form 5, Page 1 of 2, Rev. 8/15

Occupational Therapy Form 5 - Application For A Limited Permit - New York The State Education Department

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