The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
Verify New York State Licensure (Certification)
A Certification of licensure is an official written statement of the basis of licensure in New York State, including
such items as professional school attended and professional examination results which may be required for
licensure in another jurisdiction. This also includes national credentialing organizations (CGFNS, FCCPT,
NCEES, NCARB etc.). Please Note: This statement will only be issued at the request of the licensee. In
New York State, a certification is used to verify a New York State license for the purposes of
endorsement to another state. Many states use the word 'Verification' for this document.
1. Licensee Information
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Birth Date
Month Day Year
Print Name
Mailing Address
(You must notify the Department promptly of any address or name changes)
Line 1
Line 2
Line 3
State ZIP Code
Telephone/Email Address
Daytime Phone
Area Code Phone
Email Address (please print clearly)
Profession License Number
Name originally licensed under (If different than above)
You can view an official online verification of any New York State professional license at no cost by using our online verification of licensure service available
at To request an official written statement contact the Certification and Verification Unit by email at or by phone at
518-474-3817 Ext. 1-390. There is an additional fee per request.
Mail this form and fee to: New York State Education Department, Office of the Professions, Certification and Verification Unit, 89 Washington Avenue,
Albany, NY 12234. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
2. Name and Address to which certification is to be sent
City State ZIP Code
3. Licensee Signature
Licensee's Signature Date
Print Name
Verify New York State Licensure (Certification), Revised 1/18
Complete this form. Enclose the $20 fee and submit this form with with any accompanying documents (such as another jurisdictions' forms) to
the Office of the Professions at the address at the end of the form. Do not send cash. Make check or money order payable to the New York
State Education Department. We cannot accept payment by Credit Card. A separate request form and fee must be submitted for each
certification requested. Please note: Payment submitted from outside the United States must be made by check or draft on a United States
bank and in United States currency; payments submitted in any other form will not be accepted and will be returned.