Fillable Lcsw3 LCSW 3 (New York State Education Department)

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Lcsw3 LCSW 3 (New York State Education Department)

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The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Licensed Clinical Social Worker Form 3
Verification of Other Professional Licensure/Certification
Complete this form if you hold, or have ever held, a license or certificate to practice any profession* in any jurisdiction
*Profession is defined as professional titles licensed under New York State Education Law.
Applicant Instructions
1. Complete Section I. In item 3, enter your name exactly as it appears on your Application for Licensure (Form 1). Be sure to sign and
date item 8.
2. Send the entire form to the appropriate licensing/certifying authority for completion of Section II. Be sure to include any fee required
by that licensing/certifying authority. We must receive a Form 3 for all professional licenses/certificates you ever held except those
issued by the New York State Education Department. This form will not be accepted if submitted by the applicant.
Note: Completion of this form does not substitute for the submission of other required documents by the verifying entity, including
Form 4B to verify supervised experience, Form 4Q to document the supervisor's qualifications and examination scores from ASWB.
Section I - Applicant Information
1. Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2. Birth Date
Month Day Year
3. Print Your Name Exactly As It Appears On Your Application for Licensure (Form 1)
Last
First
Middle
4. Mailing Address (You must notify the Department promptly of any address or name changes)
Line 1
Line 2
Line 3
City
State ZIP Code
Country/
Province
5. Name of licensing/certifying authority to which this form is being sent
6. Print your name as it appears on your license/certificate from the licensing/certifying authority listed in item 5.
Print name
Professional title on license/certificate issued
7. Did you complete the examination required for licensure/certification under any non-standard conditions?
(e.g., the use of a dictionary or extra time for applicants whose primary language is other than English)
Yes No
8. I request and give my permission to the licensing/certifying authority listed in item 5 above to complete the information on this form and
mail it to the New York State Education Department and to release any other information required by the State Education Department in
connection with my application for licensure. I also declare and affirm that the statements made in this application, including
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 licensure and may result in criminal prosecution.
Applicant's Signature Date
Licensed Clinical Social Worker Form 3, Page 1 of 2, Revised 8/17
Section II - Verification of Licensure/Certification (Please print or type)
Instructions to the Licensing/Certifying Authority: Please complete items 1-4, sign and date the certification and return both pages of this
form in an official envelope directly to the Office of the Professions at the address below. This form will not be accepted if returned by the
applicant. Attach additional sheets if necessary.
1. Name of the applicant
(see Section I, item 6)
2. Professional title on license/certificate
License/certificate number Date of licensure/certification
mo. day
yr.
3. Verification of licensure/certification - Complete if applicant was licensed/certified as a social worker in your jurisdiction.
What requirements did the applicant meet to become licensed/certified as a social worker in your jurisdiction?
Education: Diploma/Degree
Examination: Oral Examination Title Date
mo. day yr.
Score
Written Examination Title Date
mo. day yr.
Score
Supervised Experience:
None
year(s) Describe
Endorsement of license from or reciprocity with
(name of jurisdiction)
Grandparented
4. A. Has the applicant identified in Section I been subject to any disciplinary action? Yes No
B. Are any charges pending against this license?
Yes No
If the answer to either A or B is "yes", please attach a complete explanation with any supporting documentation.
Certification
I hereby certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named on this form. I
further certify that, except as noted in item 4 above or in any attachments, this licensing/certifying authority has never taken any disciplinary
action against this person and that in so far as the licensing/certifying authority has knowledge, there have been no charges preferred nor has
any information been presented relating to any question of unprofessional or immoral conduct.
Signature Date
Print Name
Title
License/certifying authority
Address
Telephone Fax
Email
Seal
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Social Work
Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Licensed Clinical Social Worker Form 3, Page 2 of 2, Revised 8/17
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Lcsw3 LCSW 3 (New York State Education Department)

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Completed 22 July 2020

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