Application for Replacement Registration Certificate
The University of the State of New York The State Education Department Office of the Professions
Division of Professional Licensing Services op.
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
For Department Use Only
Last First Middle
License #: Name Check: Fee: $10
Licensee business address, phone and email address are public information. Failure to
Profession #:
indicate business or home on this form for each item will deem it public information.
Year:
RC
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
Country/ Province
ZIP Code
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 Contact Email
Phone 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.
Application for Replacement Registration Certificate, Rev. 5/19
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