Fillable Licensed Clinical Social Worker Form 4E Endorsement Applicant (New York State Education Department)

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Licensed Clinical Social Worker Form 4E Endorsement Applicant (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 4E
Endorsement Applicant Experience Record
This form is for applicants seeking licensure in New York State by endorsement of a license to practice clinical social
work issued in another jurisdiction. You must have at least 10 years of licensed experience in clinical social work, in
the 15 year period prior to applying for licensure in New York State
Applicant Instructions
1. Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to
sign and date item 9.
2. For your experience, you must also complete Section I of Form 4F and forward the entire form to each colleague you list in item 8 on
this form.
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. Telephone/Email Address
Daytime Phone
Area Code Phone
Email Address (please print clearly)
6. Date of award of Graduate Social Work Degree
mo. day yr.
7. Give any other names by which you have been known
Licensed Clinical Social Worker Form 4E, Page 1 of 2, Revised 8/17
8. List colleague(s) who will verify your experience for licensure as an LCSW. Attach additional sheets if necessary.
The colleague(s) listed must have knowledge of your experience in diagnosis, psychotherapy and assessment-based treatment plans for
at least 10 years in the 15 years prior to your application.
Assigned
Number
Name of Colleague and Address of Experience Setting
Dates of Experience
From To
1
2
3
4
5
6
7
9. Attestation
I declare and affirm that the statements made in the foregoing application, including accompanying statements 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 of
qualification and may lead to a filing of charges of professional misconduct.
Signature of Registrar Date
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 4E, Page 2 of 2, Revised 8/17
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Licensed Clinical Social Worker Form 4E Endorsement Applicant (New York State Education Department)

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Completed 1 September 2021

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