Submit a request

Full Name (Last, First)

Are you currently licensed in New York State (NYS)?

Select Your Profession

6-digit NYS License Number including any leading zeroes. Do not use letters, dashes or numbers after dashes.

If you do not know your license number, you can look it up here: http://www.op.nysed.gov/opsearches.htm#nme

Date Of Birth

Please use MM/DD/YYYY format. ex. 01/10/1965

Do you have a Social Security Number (SSN)?