Physician Assistant Form 5 - Application For Limited Permit - New York The State Education Department
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1
2The University of the State of New York
Department Use Only
Registered Physician
THE STATE EDUCATION DEPARTMENT
Assistant Form 5
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
Application for Limited Permit
APPLICANT INSTRUCTIONS
1.
After submitting an application for licensure as a registered physician assistant in New York State,
you may file an application for a limited permit to practice pending receipt of the license. A limited
permit authorizes practice as a physician assistant under supervision of a physician licensed and
currently registered in New York State. When applying for a limited permit, it is your responsibility to
ensure that your prospective supervisor fully completes the Certification of Supervision, Section II.
2.
Complete Section I and forward the form to your employer. Be sure to sign and date item 9. Limited
permits expire one year from the date of issue. You should be certain you are ready to begin practice
1
23
$105
PR
when you apply for the limited permit.
3.
Submit this application with a check or money order for the required fee of $105 made payable to the
Permit number
New York State Education Department, to the Office of the Professions at the address at the end of
this form. If you have not already done so, you must submit an Application for Licensure (Form 1) and
the licensure fee with this form and the limited permit fee. The permit application cannot be approved
Date issued
until all required documents have been received and approved. You may not begin practice until
the limited permit is issued.
If you change or add employers or supervisors after the permit is issued, you must obtain a new
4.
Date expires
permit. You may obtain a new permit by completing, with your prospective employer, a new form 5
and returning it to the Office of the Professions. A fee is not required for a new permit issued as a
result of a change in employment. An additional fee of $105 is required for an extension.
Initials
SECTION I: APPLICANT INFORMATION
6
2
Telephone/E-Mail Address
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Daytime Phone
3
Month
Day
Birth Date
Year
Area Code
Phone Number
4
Print Name
E-Mail Address (Please print clearly)
Last
First
Middle
7
I am applying for:
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
Original permit
Line 1
Additional/change of supervisor
(No fee required)
Line 2
Additional/change of employer
(No fee required)
Line 3
Extension
City
State
Zip Code
Country/
Province
8
Name of prospective employer: _____________________________________________________________________________
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.
_____________________________________________________________________________
__________________________________
Signature of applicant
Date
Registered Physician Assistant Form 5, Page 1 of 2, Rev. 8/15
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