Application Forms for Medical Physics

All applicants for licensure must initially submit Form 1 along with the $495 licensure and first registration fee (. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.
 

All applicants for licensure must initially submit Form 1 along with the $495 licensure and first registration fee (. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.
 

All applicants for licensure must initially submit Form 1 along with the $495 licensure and first registration fee (. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

All applicants for licensure must initially submit Form 1 along with the $495 licensure and first registration fee (. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.
 

Please note: This form must be submitted directly by the educational institution you attended.

• Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 8. Be sure to include any fee required by the school. A separate Form 2 should be submitted for each educational program attended that will demonstrate satisfaction of the professional education requirement.
• Section II: The Registrar or appropriate school official must complete this section and return the form in a school envelope directly to the Office of the Professions at the mailing address at the end of the form.
  • Graduates of Master's and Doctoral programs from accredited United States colleges or universities must send this form to each college/university where you attended a graduate level program and request that each school complete the appropriate parts of Section II of this form and return it directly to the Office of the Professions with an official transcript.
  • Graduates of Master's and Doctoral programs from colleges or universities located outside the United States and not accredited by a U.S. accreditation body must send this form to every college/university attended and request each school to complete the appropriate parts of Section II of this form and return it directly to the Office of the Professions with an official transcript.

Electronic Education Documentation

The Office of the Professions (OP) will accept official electronic transcripts and forms from educational institutions (i.e. colleges/universities) or designated third-party* transcript entities located in the United States provided that:

• The transcript is the certified true and official academic record and the document does NOT have an expiration date**.
• OP can independently verify that the documentation is received directly from the educational institution’s registrar or officially designated third-party.
• If a third-party transcript provider is involved, it is clear that the educational institution has designated the third party as the official sole provider of its transcripts.
• The applicant had no opportunity to directly access or alter the transcript before it is sent or transmitted.
• Any educational institution education documentation submissions should be made electronically to DPLSEduc@nysed.gov***.

*OP will only accept third-party submissions after we have determined that the arrangement between the educational institution and the third party is consistent with our security and verification standards.

**Transcript documents with expiration dates cannot be accepted. Expirations on links to the document are acceptable.

***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.

Complete this form and send it to the address at the end of the form. Be sure to sign and date item 6 and list all professional medical physicist work experience chronologically, beginning with your first employer to the present. Provide the name and address of each employer and the specialty area you practiced with each employer. Attach additional sheets if needed.

You should transcribe the professional experience information, including a comprehensive description of your professional experience, from the Form 4 to an individual Form 4A for each endorser you list (for more information see Form 4A Instructions)

Instructions for Completing Verification of Professional Experience.

This form must be sent directly by the endorser.

• Section I: Complete this section and forward the form, along with a copy of the instructions, to the individual endorser who will attest to your practice of medical physics. Be sure to sign and date the attestation.
• Section II: Have your endorser complete this section, sign and date the attestation and send the form directly to the Office of the Professions to the address at the end of the form. This form will not be accepted if submitted by the applicant.

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.

All applicants for a limited permit must initially submit Form 5 along with the $60 limited permit fee. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit along with your application.

Continuing Your Application If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Supervisors and/or Settings
If you change supervisors and/or settings, or you have to add or remove a supervisor or setting, after a permit is issued, you must obtain an amended permit using the Limited Permit Change Form. After changes are processed you will receive an amended permit. A fee is not required for an amended permit issued as a result of a change in supervisor or setting. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit for each new supervisor you are adding (see Upload Additional Documentation above).

All applicants for a limited permit must initially submit Form 5 along with the $60 limited permit fee. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit along with your application.

Continuing Your Application If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Supervisors and/or Settings
If you change supervisors and/or settings, or you have to add or remove a supervisor or setting, after a permit is issued, you must obtain an amended permit using the Limited Permit Change Form. After changes are processed you will receive an amended permit. A fee is not required for an amended permit issued as a result of a change in supervisor or setting. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit for each new supervisor you are adding (see Upload Additional Documentation above).

All applicants for a limited permit must initially submit Form 5 along with the $60 limited permit fee. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit along with your application.

Continuing Your Application If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Supervisors and/or Settings
If you change supervisors and/or settings, or you have to add or remove a supervisor or setting, after a permit is issued, you must obtain an amended permit using the Limited Permit Change Form. After changes are processed you will receive an amended permit. A fee is not required for an amended permit issued as a result of a change in supervisor or setting. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit for each new supervisor you are adding (see Upload Additional Documentation above).

All applicants for a limited permit must initially submit Form 5 along with the $60 limited permit fee. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit along with your application.

Continuing Your Application If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Supervisors and/or Settings
If you change supervisors and/or settings, or you have to add or remove a supervisor or setting, after a permit is issued, you must obtain an amended permit using the Limited Permit Change Form. After changes are processed you will receive an amended permit. A fee is not required for an amended permit issued as a result of a change in supervisor or setting. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit for each new supervisor you are adding (see Upload Additional Documentation above).

This form is not for all applicants. Use this form ONLY if you are applying/have applied for a New York State Limited Permit as a Medical Physicist online
 

• Section I: Complete this section.
• Section II: Your supervisor must complete this section before you can submit it to the Office of the Professions at the appropriate address at the end of the form. It is your responsibility to ensure your supervisor fully completes Section II. Failure to complete this form will delay its review.