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
Application for Replacement*
Registration Certificate
*This application is only for a replacement registration certificate.
Once issued, the replacement registration certificate will void all other previously issued registration certificates.
Instructions: Complete this form before submitting it and the $10 fee to the Office of the professions at the address at the end of the form.
Print Name
Last
First
Middle
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
Mailing Address Home or Business
(You must notify the Department within 30 days of any address or name changes)
Line 1
Line 2
Line 3
City
State ZIP Code
Country/
Province
Profession
New York State License Number
-
Birth Date
Month Day Year
Last 4 Digits of Social Security Number
Daytime Telephone Number
Home or Business
Area Code Phone
Contact Email
Home or Business
Mail this form and $10 fee to: New York State Education Department, Office of the Professions, Registration Unit, 89 Washington
Ave, Albany, NY 12234-1000. DO NOT SEND CASH. Make check or money order payable to the New York State Education
Department.
For Department Use Only
License #:
Name Check:
Fee: $10
Profession #:
Year:
RC
Application for Replacement Registration Certificate, Rev. 5/19
