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License Application Forms
Instructions for completing and submitting the forms required for licensure appear below. You may also need to submit additional information (for example, examination scores). Please refer to the license requirements link on the left for complete information regarding all requirements you must meet.
Note: All forms are in Adobe Portable Document Format (PDF). To view or print these documents, you will need to have the free Adobe Reader installed on your computer. Download times and print quality will depend on your connection speed and printer.
Please type or print all information and sign all forms in black or blue ink. Please indicate the professional license you are applying for by checking the Physical Therapist or Physical Therapist Assistant box in the upper left hand corner of each form.
All applicants for licensure must complete this form and submit it with the licensure fee directly to the Office of the Professions at the mailing address at the end Form 1. Make checks payable to the New York State Education Department. NOTE: Your cancelled check is your receipt. You must answer all questions and provide all information requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review.
Address/Name Change Form – Optional ( 20 KB) You are required to notify us within 30 days of any name or address changes. Please read the instructions and complete the appropriate sections of this form.
Form 2 – Certification of Professional Education ( 13 KB) This form must be submitted directly from the educational institution you attended.
- If you are a graduate of a program registered by the New York State Education Department as licensure qualifying or accredited by the American Physical Therapy Association (APTA), you must complete Form 2 as follows:
- Section l: Complete this section of the form before sending it to your educational institution, then forward this form to your academic institution for completion of Section ll, Part A and Part B. Be sure to sign and date item 8.
- Section ll: Have your school complete this section and forward it directly to the Office of the Professions. The Registrar or appropriate school official must return the completed form directly to the State Education Department, Office of the Professions, Division of Professional Licensing Services, Physical Therapy Unit, 89 Washington Avenue, Albany, NY 12234-1000.
- If you are applying for licensure based upon an education program that is outside the United States and NOT accredited by the American Physical Therapy Association (APTA), do not use Form 2. You must have your educational credentials verified by an independent credentials verification organization. Please refer to the Education Requirements section for the proper procedure.
Form 3 – Certification of Physical Therapist or Physical Therapist Assistant Licensure in Another State ( 14 KB) If you are or have been licensed as a physical therapist or physical therapist assistant in another state or U.S. territory, you must also submit Form 3 to verify your license. A separate Form 3 must be sent directly from each jurisdiction in which you currently or previously held a license.
- Section I: Complete this section of the form before sending it to the licensing authority. Make sure to include any fee required by that licensing authority for the certification or verification of a license. Be sure to sign and date item 7.
- Section II: The state or U.S. territory in which you have previously applied for a license or been issued a license must complete this section and forward it directly to The Office of the Professions. The licensing authority must apply an original signature and stamp or seal and return the form directly to:
The NYS Education Department
Office of the Professions
Division of Professional Licensing Services
Physical Therapy Unit
89 Washington Avenue
Albany, NY 12234-1000.
Form 4 – Endorsement Applicant Professional Experience Record ( 13 KB) This form is for applicants seeking licensure in New York State by endorsement of a license to practice physical therapy issued in another jurisdiction.
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 8.
You must also complete a separate Form 4A for each colleague you list on the Endorsement Applicant Professional Experience Record (Form 4).
Form 4A – Certification of Professional Experience for Endorsement Applicants ( 18 KB) This form must be submitted directly by a colleague. The Office of the Professions will not accept this form if submitted by the applicant.
- Section I: Complete this section and send the entire form to your colleague to complete Section II. Be sure to sign and date item 7.
- Section II: The colleague must complete this section, sign and date the form and return the entire form directly to the Office of the Professions at the mailing address at the end of the form.
Form 5 – Application For Limited Permit ( 17 KB) If you are seeking a limited permit, complete section l of this form, have your employer read section II and complete section III, and submit it with the appropriate fee ($70 for physical therapists, $50 for physical therapist assistants) to the address at the end of the form.
Applicants for a limited permit must complete this form in addition to the Application for Licensure (Form 1). Do not send cash. Make checks or money orders payable to the New York State Education Department.
Last Updated: March 29, 2017