Certified Dental Assisting - Application For Licensure - The University Of The State Of New York The State Education Department - 2016
ADVERTISEMENT
1
2
3
4Department Use Only
The University of the State of New York
Certified Dental Assisting
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 1
Division of Professional Licensing Services
Application for Licensure
Applicants Must Complete All Pages of This Application In Ink
All applicants for licensure must complete this form and submit it with the $103 licensure and first registration fee directly to
the Office of the Professions at the address at the end of this form. You must answer all questions and provide all information
49 $103
ER
1
requested unless otherwise indicated. Failure to complete all required parts of the application will delay its review. You must
sign and date the Affidavit on this form in the presence of a Notary Public.
NYS License Number
2.
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Date Issued
3
3.
Birth Date
Month
Day
Year
Initials
4
4.
Print Name
6
6.
Telephone/E-Mail Address
Last
Daytime phone
First
Home or Business
Middle
Area Code
Phone
Licensee business address, phone and e-mail address are public information. Failure to
E-mail Address
(please print clearly)
indicate business or home on this form for each item will deem it public information.
Home or Business
5
5.
Mailing Address:
Home or Business
(You must notify the Department promptly of any address or name changes.)
Line 1
6.
New York State DMV ID Number
7
Line 2
(Driver or Non-Driver ID)
Line 3
(Leave this blank if you do not have a New
City
York State DMV ID Number)
State
Zip Code
Country/
Province
8
7.
Name as it appears on degree or other credentials (if different from above): ________________________________________________
Other names you have been known by: ____________________________________________________________________________
9
Yes
No
9.
Have you previously applied for New York State licensure in any profession?
If “yes”, in what profession(s)? ____________________________________________________________________________________
10
Yes
No
10. Have you taken the DANB exam?
If “yes”, when? Date: _______ / _______ / _______
mo.
day
yr.
Certified Dental Assisting Form 1, Page 1 of 4, Rev. 6/16
ADVERTISEMENT
0 votes
Related Articles
Related forms
Cytotechnologist/certified Histological Technician - Application For Licensure - The University Of The State Of New York The State Education Department - 2016
Legal
State University Of New York Medical Reimbursement Form - Claims Incurred Inside The United States
Legal
Application For Alcoholic Beverage Control Manufacturer License(s) - Stateof New York Liquor Authority
Legal
Applied Behavioranalysis - Application For Licensure/certification - The University Of The State Of New York The State Education Department - 2016
Legal
Creative Arts Therapy - Application For Licensure - The University Of The State Of New York The State Education Department - 2016
Legal
Psychoanalysis Form 1 - Application For Licensure - The University Of The State Of New York The State Education Department - 2016
Legal
Related Categories
Parent category: Legal