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Form 4E - Endorsement Applicant Experience Record

This form is for applicants seeking licensure in New York State by endorsement of a license to practice clinical social work issued in another jurisdiction. You must have at least 10 years of licensed experience in clinical social work, in the 15 year period prior to applying for licensure in New York State.

Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 9.

You must also complete a separate Form 4F for each colleague you list on the Endorsement Applicant Experience Record (Form 4E).