Form 2b - Verification Of Post-Doctoral Education In Use Of Parenteral Conscious Sedation
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1
2The University of the State of New York
DEPARTMENT USE ONLY
Dental Anesthesia/Sedation
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Certification Form 2B
Approved: _________________
Division of Professional Licensing Services
89 Washington Avenue
Date: ____________________
Albany, NY 12234-1000
Dental Parenteral
Conscious Sedation
VERIFICATION OF POST-DOCTORAL EDUCATION IN USE OF
PARENTERAL CONSCIOUS SEDATION
APPLICANT INSTRUCTIONS
1.
Complete Section I. Enter your name as it appears on your application Form 1. Please be sure to sign and date item 8.
2.
Send this form to the institution at which you received your training or served your residency for completion of Section II on page 2.
3.
The institution which completes Section II must send this form directly to the Division of Professional Licensing Services. It will not be accepted if
submitted by the applicant.
SECTION I: APPLICANT INFORMATION
1
2
3
Social Security
Birth
Number:
Date:
New York State License Number
mo .
day
yr.
(Leave this blank if do not you have a U.S. Social Security Number)
4
Print Your Full Name Exactly As It Appears On Your Certification Application (Form 1)
Last
First
Middle
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
6
Name of Institution: __________________________________________________________________________________________
Dates of attendance:
from __________ / __________ / __________ to __________ / __________ / __________
mo.
day
yr.
mo.
day
yr.
7
Print name under which program was completed: __________________________________________________________________
I request and give my permission to the institution listed in item 6 above to complete the information on this form and send any
8
documentation requested by the NYS State Education Department including that listed on page 2 of this form (e.g. an official
transcript) to the New York State Education Department's Division of Professional Licensing Services.
Applicant's signature: __________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Dental Anesthesia/Sedation Certification Form 2B, Page 1 of 2, Rev. 11/05
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