Certified Dental Assisting - Application For Licensure - The University Of The State Of New York The State Education Department - 2016 Page 2
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Please print clearly giving an accurate record of your educational preparation below. YOU MUST COMPLETE ALL INFORMATION FOR
ALL SCHOOLS/COLLEGES/UNIVERSITIES ATTENDED AND DIPLOMAS AND/OR DEGREES RECEIVED OR YOUR APPLICATION
WILL BE CONSIDERED INCOMPLETE. Attach additional sheets if necessary.
Name of High School/Secondary School or GED Diploma issuer: _____________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Graduation date: _______ / _______
or
Date G.E.D. issued: _______ / _______
mo.
yr.
mo.
yr.
G.E.D. Number: ___________________________
Postsecondary School (Excluding Dental Assisting Programs)
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
Dental Assisting Program
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
12
18. Gender and Ethnicity: (This item is optional.)
Information on gender and ethnicity is sought solely to allow the Education Department to collect and analyze data concerning diversity
in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and program evaluation
purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for licensure.
Male
Female
Gender:
White (not Hispanic)
Black (not Hispanic)
Asian
Hispanic
Native American
Ethnicity:
Certified Dental Assisting Form 1, Page 2 of 4, Rev. 6/16
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