Occupational Therapy/occupational Therapy Assistant - Application For Licensure/authorization - The University Of The State Of New York The State Education Department - 2016
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The University of the State of New York
Occupational Therapy
THE STATE EDUCATION DEPARTMENT
Occupational Therapy Assistant
Office of the Professions
Division of Professional Licensing Services
Form 1
Application for Licensure/Authorization
Applicants Must Complete All Four Pages of This Application In Ink
You must complete this form and submit it with the appropriate licensure and initial registration fee directly to the Office of the
Professions at the address at the end of this form to apply for licensure in NYS. You must answer all questions and provide
all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its
review. You must sign and date the Affidavit on this form in the presence of a Notary Public.
1.
Check what you are applying for:
1
NYS License Number
Occupational Therapist (License)
63 $294
ER
Occupational Therapy Assistant (Authorization)
64 $147
ER
Date Issued
2
2.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Initials
3
3.
Birth Date
Month
Day
Year
4
4.
Print Name
6
6.
Telephone/E-Mail Address
Last
Daytime phone
First
Home or Business
Middle
Area Code
Phone
Licensee business address, phone and e-mail address are public information. Failure to
E-mail Address
(please print clearly)
indicate business or home on this form for each item will deem it public information.
Home or Business
5
Mailing Address: Home or Business
5.
(You must notify the Department promptly of any address or name changes)
Line 1
6.
7
New York State DMV ID Number
Line 2
(Driver or Non-Driver ID)
Line 3
City
(Leave this blank if you do not have a New
York State DMV ID Number)
State
Zip Code
Country/
Province
8
8.
Name as it appears on degree or other credentials (if different from above): ________________________________________________
Yes
No
9.
9
Have you previously applied for New York State licensure in any profession?
If “yes”, in what profession(s)? _______________________________________________________________
Yes
No
10
11. Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime
(felony or misdemeanor) in any court?
Yes
No
12. Are criminal charges pending against you in any court?
11
13. Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of,
12
suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined,
Yes
No
censured, reprimanded or otherwise disciplined you?
Yes
No
14. Are charges pending against you in any jurisdiction for any sort of professional misconduct?
13
15. Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever
14
Yes
No
voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures?
NOTE: If you answer "Yes" to any questions numbered 10-14, submit a letter giving a complete detailed explanation. Include copies of any court
records including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. If the court can no
longer provide documentation, you must request, from the court, a letter stating why they cannot provide the documents.
Occupational Therapy Form 1, Page 1 of 4, Rev. 6/16
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