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  • Section I: Complete this section of the form before having your prospective supervisor complete Section II. Please be sure to sign and date item 9.
  • Section II: Your prospective supervisor must complete this section. You must meet all other requirements for licensure except the examination and experience requirements, in order to be eligible for a limited permit.

In addition to the Form 5 and $70 limited permit fee, you must submit the Application for Certification (Form 1) and the appropriate fee for certification and first registration. The Department must approve your education before your application for a limited permit can be approved. Return the completed Form 5 to the Office of the Professions at the address at the end of the form.
For further information on permanent certification provisions, please see  certification requirements.