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Application Forms for Speech-Language Pathology

Important Notice: DO NOT use Form 1 if you are already licensed in this profession in New York State. A New York State professional license is valid for life unless it is revoked, annulled, or suspended by the Board of Regents. To practice in New York State, your professional license must be registered. To renew your registration online, visit http://op.nysed.gov/services/online-registration-renewal. If your registration has lapsed for longer than 4 months, submit a Delayed Registration Application.

All applicants for licensure must initially submit Form 1 along with the $294 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.
 

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Do I need to apply for a Limited License in Speech-Language Pathology? Click here for more information.

This form is to be used ONLY by individuals who are applying for a speech-language pathology license and have yet to complete the experience requirement. Click here for more information.

All applicants for limited licensure must submit Form 1LL and the $70 fee along with, or after submitting an Online Application for Licensure (Form 1). 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. 

  • Section I: Complete this section and forward this form to the licensed speech-language pathologist who will be supervising your experience. Be sure to sign and date item 9.
  • Section II: The supervisor must complete this section and return the entire form to the Office of the Professions to the address at the end of the form.

Change Address or Name

You are required to notify us within 30 days of any address or name changes. Please read the instructions to request this change.

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If you received your graduate degree before April 1, 1976, do not use this form. Have your school(s) send undergraduate and graduate transcripts to the Office of the Professions. Verification from school(s) must also include practicum information.

This form must be submitted directly by the educational institution. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section of the form before sending it to your school. Be sure to sign and date item 9.
  • Section II: The registrar or appropriate school official must complete this section, sign and date and return the form in an official school envelope directly to the Office of the Professions at the address at the end of the form.

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, Canada, and the Philippines 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.

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Complete this form if you hold, or ever held, a license or certificate to practice any profession* in any jurisdiction.

This form must be submitted directly by the licensing/certifying authority. 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 licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
  • Section II: The licensing/certifying authority 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.

Note: A Form 3 is not required for licenses/certificates issued by the New York State Education Department. Also, If the certification/verification documentation provided by a U.S. jurisdiction contains the same information requested in the Form 3, completion of a Form 3 for that jurisdiction is not necessary. For certification/verification documentation that does not contain the same information, a Form 3 will need to be completed for that jurisdiction.

Please photocopy this form as needed.

*Profession is defined as professional titles licensed under New York State Education Law. (See page 2 of the Address/Name Change Form at the end of this packet for a list of those titles.)

Electronic Verification of Licensure, Certification and/or Examination

The Office of the Professions (OP) will accept electronic verifications of licensure, certification and examination completion from other licensing authorities located in the United States provided that:

  • OP can independently authenticate that the verification is received directly from the licensing authority.
  • The applicant had no opportunity to directly access or alter the verification before it is sent or transmitted.
  • Any licensing authority verification submissions should be made electronically to DPLSVerif@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.

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This form should be submitted at the beginning of your supervised experience. When the Application for Licensure (Form 1), the fee, Certification of Professional Education Form (Form 2), and Identification of Supervisor and Setting Form are received and approved, you will receive verification (Form 6).

If application is not made until after the supervised experience begins, or at the end of the experience, it is still necessary to complete and submit this form.

  • Section I: Complete this section and ask your employer and/or supervisor to complete Section II, Part A.
  • Section II: Complete parts B, C and D of this section with your employer and/or supervisor and then return the entire form directly to the Office of the Professions at the address at the end of the form.
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Your supervisor must send this form directly to the Office of the Professions at the end of the supervised experience. The Office of the Professions will not accept this form if it is submitted by the applicant.
 

  • Section I: Complete this section before sending the entire form to your supervisor. Be sure to sign and date item 7 once the work experience is complete.
  • Section II: Your supervisor must review this section and complete the attestation then return both pages of the form directly to the Office of the Professions at the address at the end of the form.

If you completed your experience in the past and are certified by the American Speech-Language Hearing Association (ASHA), you may send a copy of the Clinical Fellowship Year (CFY) Plan and Report for consideration directly to the Office of the Professions at:

New York State Education Department
Office of the Professions
Division of Professional Licensing Services
Speech-Language Pathology and Audiology Unit
89 Washington Avenue
Albany, NY 12234-1000
Phone: 518-474-3817 ext. 270
Fax: 518-402-5354
E-mail: opunit3@nysed.gov

However, Forms 4A and 4B are preferred, especially if the experience requirement was completed in New York State within the last five years. You may contact ASHA at:

ASHA
2200 Research Blvd.
Rockville, MD 20850-3289
Phone: 800-498-2071
E-mail: actioncenter@asha.org
Web: www.asha.org

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This form must be submitted directly by the licensed speech-language pathologist or audiologist who will endorse your license application. The Office of the Professions will not accept this form if submitted by the applicant. This form is to be used only by individuals already licensed as a Speech-Language Pathologist or Audiologist in another state or jurisdiction.

  • Section I - Complete this section and forward this form to the licensed speech-language pathologist or audiologist who will endorse your licensure application (the endorser must be licensed in the jurisdiction where you were employed). Be sure to sign and date item 7.
  • Section II - The endorser must complete this section and return the entire form 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.
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