Form 4b-Certification Of Completion Of Clinical Residency Program
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1
2The University of the State of New York
Dentist
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 4B
Division of Professional Licensing Services
Certification of Completion of Clinical Residency Program
Applicant Instructions
You may complete either a specialty dental residency program or a general dentistry residency program. The program must be accredited
by an approved national accrediting body and of at least one year's duration. Please confirm with your residency program director that the
residency program is participating in this route to licensure.
1.
Complete Section I. In item 3, enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 6.
2.
Have your residency program director complete Section II certifying your successful completion of the residency program. The
residency program director must return both pages of this form directly to the Office of the Professions at the address at the end of this
form.
Section I: Applicant Information
2
1
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
3.
Print Name As It Appears on Your Application for Licensure (Form 1)
Last
First
Middle
4
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
5.
Name of hospital or school where you completed the residency program (please type or print):
_____________________________________________________________________________________________________________
Name of accredited residency program:
_____________________________________________________________________________________________________________
Dates of residency program: _______ / _______ / _______ to: _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
6
6.
I request and give my permission to the hospital or school listed in item 5 above to complete this form and mail it to the New York State
Education Department, and to release any other information requested by the State Education Department in connection with my
application for licensure.
Applicant's Signature: ______________________________________________________________ Date:_______ / _______ / _______
mo.
day
yr.
Dentist Form 4B, Page 1 of 3, Rev. 8/15
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