Dental Education Record Form

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The University of the State of New York
Dental Education
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Record Form
Division of Professional Licensing Services
Dental Education Record Form
(Use this form only if your dental degree was awarded from a school outside the United States or Canada)
Instructions: Please complete both pages of this form and submit it to the Office of the Professions at the address at the end of the form.
1
1.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2
2.
Birth Date
Month
Day
Year
3
3.
Print Name Exactly as You Wish It to Appear on Your License
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.
E-mail: _____________________________________________________________________________________________________
6
6.
Citizenship/Immigration Status:
Federal law limits the issuance of professional licenses, registrations and limited permits to United States citizens or qualified aliens. To
comply with this Federal law, complete this section of this form and check the appropriate box below which indicates your
citizenship/immigration status.
I am:
A.
F.
A United States citizen or National.
An alien whose deportation is being withheld under Section 241
(b)(3) of the Immigration and Nationality Act.
B.
An alien lawfully admitted for permanent residence in the United
States.
G.
An alien granted conditional entry pursuant to Section 203 (a)(7)
of the Immigration and Nationality Act as in effect prior to April
C.
An alien granted asylum under Section 208 of the Immigration
1980.
and Nationality Act.
H.
Non Immigrant (Temporarily in U.S.)
D.
A refugee granted asylum under Section 207 of the Immigration
Please list Visa type or immigration status or attach a copy of
and Nationality Act.
your passport if you are not required to have a Visa to enter the
E.
An alien paroled into the United States under Section 212 (d)(5)
United States: _______________________________________
of the Immigration and Nationality Act for a period of at least 1
year.
If you checked any of the boxes from B-H, enter your alien registration number or control number issued by the United States
Citizenship and Immigration Services (USCIS):
USCIS number: ___________________________________________
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL
LAW SHOULD BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283,
OR VISITING THEIR WEB SITE AT
Dental Education Record Form, Page 1 of 2, Rev. 4/15

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