This form is for Clinical Laboratory Technologist Provisional Permit applicants ONLY.
If you have held a New York State Limited License for Clinical Laboratory Technology or Certified Histological Technician DO NOT USE THIS FORM. Use Form 5PP ONLY.
This form must be submitted directly by the Clinical Laboratory Director/Principal Reseacher of the clinical or research laboratory where you received your training/experience. The Office of the Professions will not accept this form if submitted by the applicant.
- Section I: Complete this section before sending the entire form to the Clinical Laboratory Director/Principal Reseacher of the clinical or research laboratory where you received your training/experience. Be sure to sign and date item 8.
- Section II: The Clinical Laboratory Director/Principal Reseacher must complete this section, sign, date and return both pages of the form 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.