Dentist Form 3 - Verification Of Other Professional Licensure/certification

Section II: Verification of Licensure/Certification: (Please print or type)

Instructions to the Licensing/Certifying Authority: Please 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 below. This form will not be accepted if returned

by the applicant. Attach additional sheets if necessary.

Name of applicant: ____________________________________________________________________________________________

(Section I, item 6)

Professional title on license/certificate: _____________________________________________________________________________

License/certificate number: ____________________________________ Date of licensure/certification: _______ / _______ / _______

mo.

day

yr.

If the applicant was licensed/certified as a dentist in your jurisdiction, was he/she licensed/certified without passing the National Board

examinations?

Yes

If yes, please explain: __________________________________________________________________________________________

____________________________________________________________________________________________________________

Has the applicant identified in Section I been subject to any disciplinary action?

Yes

Are any charges pending against this individual?

Yes

If the answer to either of these questions is "yes," please attach a complete explanation with any supporting documentation.

Certification

I hereby certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named

above. I further certify that, except as noted in item 4 above or in any attachments, this licensing authority has never taken any

disciplinary action against this person and that in so far as the licensing 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: _______ / _______ / _______

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day

yr.

Print name: ____________________________________________________________________

Title: _________________________________________________________________________

Licensing/certifying authority: ______________________________________________________

(SEAL)

Address: ______________________________________________________________________

City: ____________________________ State ____________ Zip Code ____________________

Telephone: _______________________________ Fax: _________________________________

E-mail Address: _________________________________________________________________

Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,

Dentistry Unit, 89 Washington Avenue, Albany, NY 12234-1000.

Dentist Form 3, Page 2 of 2, (Rev. 1/07)

Dentist Form 3 - Verification Of Other Professional Licensure/certification - 2007 Page 2