Form 2a - Verification Of Approved Post-Doctoral/graduate Level Education In Anesthesia Or Education In Approved Specialty Program Or Residency Page 2
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2SECTION II: VERIFICATION OF POST-DOCTORAL/GRADUATE LEVEL EDUCATION IN ANESTHESIA OR
EDUCATION IN APPROVED SPECIALTY PROGRAM OR RESIDENCY
INSTRUCTIONS TO INSTITUTION: Please complete this section and return this form directly to the Office of the Professions. It will not
be accepted if it is incomplete or if it is returned by the applicant.
I hereby certify that ______________________________________________________________________________________________
(Dentist's Name)
Attended:
a 2 year post doctoral education program in anesthesia, or
a graduate level program in oral and maxillofacial surgery
at _______________________________________________, accredited by ________________________________________________
(Dentist's School)
(Accrediting body such as CDA)
from _______________________ through _______________________ and that the above named dentist successfully completed this
program on ________________________________________.
(Date)
Please check and attach a letter of explanation with this form if this dentist did not successfully complete the training
program.
ATTESTATION
I hereby attest that to the best of my knowledge and belief the foregoing is a true statement.
Signature:______________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print or type name: ______________________________________________________
Title or official position: ___________________________________________________
Institution: ______________________________________________________________
(INSTITUTION SEAL)
(If seal not available, attach explanation)
Address: _______________________________________________________________
Telephone number: ( __________ ) _________________________________________
Fax: ( __________ ) ______________________________________________________
E-mail: _________________________________________________________________
Return Directly to:
New York State Education Department, Office of the Professions, Dentistry Unit, 89 Washington Avenue,
Albany, NY 12234-1000.
Dental Anesthesia/Sedation Certification Form 2A, Page 2 of 2, Rev. 11/05
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