Intdesform 3

The University of the State of New York
The State Education Department

Office of the Professions
Interior Design Form 3
Division of Professional Licensing Services Verification of Other Professional Licensure/Certification
www.op.nysed.gov
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. Be sure to sign and date item 9.
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
New York State Education Department. This form will not be accepted if submitted by the applicant.
Section I: Applicant Information
1. Social Security Number 2. Birth Date Month Day Year

(Leave this blank if you do not have a U.S. Social Security Number)
3. Print Name Last
First
5. Telephone/Email Address
Middle
Daytime Phone
Home or Business
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.
Area Code Phone

4. Mailing Address Home or Business
Email Address (please print clearly)
(You must notify the Department promptly of any address or name changes)
Home or Business
Line 1
Line 2
Line 3
6. New York State DMV ID Number
City (Driver or Non-Driver ID)
State ZIP Code

Country/
(Leave this blank if you do not have a
Province New York State DMV ID Number)
7. Name of licensing/certifying authority to which this form is being sent
8. Print your name as it appears on the license/certificate issued by the licensing/certifying authority listed above.
Name
Professional title on license/certificate issued
9. I request and give my permission to the licensing authority to complete the information on this form and send any documentation
requested, including that requested on this form, to the New York State Education Department at the address at the end of this form. 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.
Signature Date
Interior Design Form 3, Page 1 of 2, Revised 2/20

Section II: Verification of Licensure/Certification (Please Print)
Instructions to the Licensing/Certifying Authority: If the applicant was licensed/certified in your jurisdiction, 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 at the
end of this form. 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 8)
2. Professional title on license/certificate
License/certificate number Date of licensure/certification

mo. day yr.
3. Verification of licensure/certification
What requirements did the applicant meet to become licensed/certified in your jurisdiction?
Education: Degree/Diploma/Certificate
Examination: Examination Title Date Score

mo. day yr.
Experience: None
Year(s) Describe
Endorsement of license/certificate from or reciprocity with

(name of jurisdiction)
Grandparenting
4. A. Has the applicant been subject to any disciplinary action? Yes No
B. Are any charges pending against this license/certificate? Yes No
If the answer to either A or B is "yes", please attach a complete explanation with any supporting documentation.
Certification
I 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 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
Name of Licensing/Certifying Authority
Address Seal
Telephone Fax
Email
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Interior
Design Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Interior Design Form 3, Page 2 of 2, Revised 2/20

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The University of the State of New York

The State Education Department

1. Complete Section I. Be sure to sign and date item 9.

Section I: Applicant Information

1. Social Security Number 2. Birth Date Month Day Year

3. Print Name Last

Area Code Phone

State ZIP Code

7. Name of licensing/certifying authority to which this form is being sent

Professional title on license/certificate issued

Interior Design Form 3, Page 1 of 2, Revised 2/20

1. Name of the applicant

2. Professional title on license/certificate

License/certificate number Date of licensure/certification

Examination: Examination Title Date Score

Endorsement of license/certificate from or reciprocity with

4. A. Has the applicant been subject to any disciplinary action? Yes No

B. Are any charges pending against this license/certificate? Yes No

Name of Licensing/Certifying Authority

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