Submit a request

Full Name (Last, First)

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

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

Select Your Profession

Date Of Birth

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

Do you have a Social Security Number (SSN)?

What school did you receive your professional education from?

Old Address Street

Old Address City

Old Address State

Old Address Zip Code

Is your new address a home or business?

Note: Licensee business address is public information.

New Address Street

New Address City

New Address State

New Address Zip Code

Phone Number

Please use this format XXX-XXX-XXXX

Phone Number Type

Note: Licensee business phone is public information.