Clinical Laboratory Technology Form 5EP "Application for Clinical Laboratory Technology Exemption Permit" - New York

What Is Clinical Laboratory Technology Form 5EP?

This is a legal form that was released by the New York State Education Department - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2016;
  • The latest edition provided by the New York State Education Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Clinical Laboratory Technology Form 5EP by clicking the link below or browse more documents and templates provided by the New York State Education Department.

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Download Clinical Laboratory Technology Form 5EP "Application for Clinical Laboratory Technology Exemption Permit" - New York

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Department Use Only
The University of the State of New York
Clinical Laboratory
THE STATE EDUCATION DEPARTMENT
Technology Form 5EP
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Application for Clinical Laboratory
Exemption Permit
Applicants Must Complete All Pages of This Application In Ink
Applicant Instructions
1. A Clinical Laboratory Technology Exemption permit authorizes practice as a perfusionist under the
supervision of a physician licensed and currently registered in New York State at a hospital where you are
86
$50
PR
1
employed on a salaried basis. Complete all pages of this form, be sure to sign and date the affidavit and
submit this form along with the $50 permit fee to the Office of the Professions at the address at the end of
Permit Number
this form.
2. You must also have a Verification of Employment by Hospital (Form 5A) submitted by the Hospital where
you are employed on a salaried basis. Your permit cannot be issed until the Department receives and
approves all required documentation.
Date Issued
3. A Clinical Laboratory Technology Exemption permit holder is subject to the full disciplinary and regulatory
authority of the Board of Regents, pursuant to Title VIII of the Education Law, as if the permit were a
professional license under Article 165 of the Education Law.
Date Expires
4. All Clinical Laboratory Technology Exemption permits issued on or after October 21, 2016 will expire on
October 20, 2018 and cannot be renewed. If you change employment after a permit is issued, you must
obtain a new permit, and with the prospective employer, complete and submit a new Application for
Initials
Clinical Laboratory Exemption Permit (Form 5EP), and the $50 permit fee. A new Verification of
Employment by Hospital (Form 5A) must also be submitted. The original Clinical Laboratory Technology
Exemption permit must be signed/dated on the back and returned to the Department.
2
Social Security Number
I am applying for:
6
(Leave this blank if you do not have a U.S. Social Security Number)
3
 Original permit
Birth Date
Month
Day
Year
 Renewal of Original Permit
Additional supervisor/employer
4
Print Name
 Change of supervisor/employer
Last
First
Middle
Licensee business address, phone and e-mail address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
New York State DMV ID Number
7
(Driver or Non-Driver ID)
5
Mailing Address:
 Home or Business
(You must notify the Department promptly of any address or name changes.)
Line 1
(Leave this blank if you do not have a New
York State DMV ID Number)
Line 2
Line 3
City
State
Zip Code
Country/
Province
8
Telephone/E-mail Address
Daytime phone:  Home or Business
E-mail:  Home or Business
9
Name as it appears on other credentials (if different than above): ________________________________________________________
10
Yes
No
Have you previously applied for New York State licensure in any profession?
If “yes”, in what profession(s)? ____________________________________________________________________________________
Clinical Laboratory Technology Form 5EP, Page 1 of 3, October 2016
2.
3.
4.
5.
 
6.
 
 
8.
9.
6.
Department Use Only
The University of the State of New York
Clinical Laboratory
THE STATE EDUCATION DEPARTMENT
Technology Form 5EP
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Application for Clinical Laboratory
Exemption Permit
Applicants Must Complete All Pages of This Application In Ink
Applicant Instructions
1. A Clinical Laboratory Technology Exemption permit authorizes practice as a perfusionist under the
supervision of a physician licensed and currently registered in New York State at a hospital where you are
86
$50
PR
1
employed on a salaried basis. Complete all pages of this form, be sure to sign and date the affidavit and
submit this form along with the $50 permit fee to the Office of the Professions at the address at the end of
Permit Number
this form.
2. You must also have a Verification of Employment by Hospital (Form 5A) submitted by the Hospital where
you are employed on a salaried basis. Your permit cannot be issed until the Department receives and
approves all required documentation.
Date Issued
3. A Clinical Laboratory Technology Exemption permit holder is subject to the full disciplinary and regulatory
authority of the Board of Regents, pursuant to Title VIII of the Education Law, as if the permit were a
professional license under Article 165 of the Education Law.
Date Expires
4. All Clinical Laboratory Technology Exemption permits issued on or after October 21, 2016 will expire on
October 20, 2018 and cannot be renewed. If you change employment after a permit is issued, you must
obtain a new permit, and with the prospective employer, complete and submit a new Application for
Initials
Clinical Laboratory Exemption Permit (Form 5EP), and the $50 permit fee. A new Verification of
Employment by Hospital (Form 5A) must also be submitted. The original Clinical Laboratory Technology
Exemption permit must be signed/dated on the back and returned to the Department.
2
Social Security Number
I am applying for:
6
(Leave this blank if you do not have a U.S. Social Security Number)
3
 Original permit
Birth Date
Month
Day
Year
 Renewal of Original Permit
Additional supervisor/employer
4
Print Name
 Change of supervisor/employer
Last
First
Middle
Licensee business address, phone and e-mail address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
New York State DMV ID Number
7
(Driver or Non-Driver ID)
5
Mailing Address:
 Home or Business
(You must notify the Department promptly of any address or name changes.)
Line 1
(Leave this blank if you do not have a New
York State DMV ID Number)
Line 2
Line 3
City
State
Zip Code
Country/
Province
8
Telephone/E-mail Address
Daytime phone:  Home or Business
E-mail:  Home or Business
9
Name as it appears on other credentials (if different than above): ________________________________________________________
10
Yes
No
Have you previously applied for New York State licensure in any profession?
If “yes”, in what profession(s)? ____________________________________________________________________________________
Clinical Laboratory Technology Form 5EP, Page 1 of 3, October 2016
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11 Do you now hold, or have you ever held a license or certificate to practice any profession in any jurisdiction?
Yes
No
(If yes, list below and attach other pages as needed.)
______________________________________________ _____________________ ________________________________________
Profession
License number
Jurisdiction
______________________________________________ _____________________ ________________________________________
Profession
License number
Jurisdiction
12 Have you been subject to any disciplinary action for professional misconduct in another jurisdiction?
Yes
No
If yes, submit a letter giving a complete and detailed explanation and attach any relevant documents.
13 Child Support Obligation
Everyone applying for a professional license, permit, or registration, or any renewal thereof, must file a written statement that, as of the
date of the filing, she or he is, or is not, under an obligation to pay child support*. Individuals who are four months or more in
arrears in child support or who have failed to comply with a summons, subpoena or warrant relating to a paternity or child
support proceeding may be subject to suspension of their business, professional, drivers and/or recreational licenses and
permits. The intentional submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of
support obligations is punishable under section 175.35 of the Penal Law.
You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance
with their obligation to pay child support can be issued a credential for no more than six months in order to comply with their child
support obligations.
Check only A or B below. If you check B, you must check one of the five statements listed below it.
I am not under an obligation to pay child support
A.
OR
I am under an obligation to pay child support and (please check only one of the following)
B.
I am current and am not four months or more in arrears in the payment of child support; or,
I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or,
The child support obligation is the subject of a pending court proceeding; or,
I am receiving public assistance or supplemental security income; or,
None of the above four statements apply.
* New York State General Obligations Law, section 3-503.
14 Citizenship/Immigration Status:
Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses,
registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation, you
must complete this section of this form and check the appropriate box below which indicates your citizenship/immigration status.
I am:
 A.
A United States citizen or National.
B.
An alien lawfully admitted for permanent residence in the United States.
C.
An alien granted asylum under Section 208 of the Immigration and Nationality Act.
D.
A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
E.
An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1
year.
F.
An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
G.
An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April
1980.
H.
Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not
required to have a Visa to enter the United States: _______________________________________
I.
I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or
similar relief from deportation. Please specify: _______________________________________
J.
I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship
and Immigration Services (USCIS):
USCIS number: ___________________________________________
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL
LAW SHOULD BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283,
OR VISIT THEIR WEB SITE AT WWW.USCIS.GOV.
Clinical Laboratory Technology Form 5EP, Page 2 of 3, October 2016
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15 Gender And Ethnicity: (This item is optional.)
Information on gender and ethnicity is sought solely to allow the Education Department to collect and analyze data concerning diversity
in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and program evaluation
purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for licensure.
Male
Female
Gender:
White (not Hispanic)
Black (not Hispanic)
Asian
Hispanic
Native American
Ethnicity:
Affirmation
I declare and affirm under penalty of perjury, that the statements made in this application, including any accompanying documents, are
true, complete and correct. I understand that any false or misleading information in, or in connection with, my application may be cause
for denial or loss of permit and may result in criminal prosecution.
I also understand that while holding a permit to practice as a perfusionist in New York State that I shall be subject to the full disciplinary
and regulatory authority of the Board of Regents, pursuant to Title VIII of the Education Law, as if the permit were a professional license
issued under Article 165 of the Education Law.
Signature: ______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print Name: _____________________________________________________________________
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY
12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Clinical Laboratory Technology Form 5EP, Page 3 of 3, October 2016
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