This form must be submitted directly by the supervisor. This form will not be accepted if submitted by the applicant.
Section I: Complete this section and forward the form along with a copy of Form 4BInst to your supervisor and ask that they complete Section II.
Section II: Have your supervisor complete this section, sign and date the affirmation and send the form along with any required documentation directly to the Office of the Professions at the address at the end of the form.
Electronic Verification of Experience
The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:
- OP can independently verify that the documentation is received directly from the supervisor
- The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
- Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.
*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.