Dental Education Record Form Page 2
ADVERTISEMENT
1
215. Please print clearly giving an accurate record of your educational preparation below. Be sure to complete all information for all
7
colleges/universities attended and degrees received. Attach additional sheets if necessary.
Name of High School/Secondary School or GED Diploma issuer: ____________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Graduation date: _______ / _______
Date GED issued: _______ / _______
mo.
yr.
mo.
yr.
Postsecondary School(s) (Includes all schools attended after high school or secondary schools)
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
Name of School:_______________________________________________________________________________________________
City: ________________________________ State/Province: _________________________ Country: __________________________
Major/Concentration: ___________________________________________________________________________________________
Number of years attended: ____________________ Attendance from: _______ / _______ to _______ / _______
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): ____________________________________________________
Date Degree/Diploma/Certificate awarded: _______ / _______
mo.
yr.
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. You may also fax this form to 518-402-5354 or
e-mail it to opunit3@nysed.gov.
Dental Education Record Form, Page 2 of 2, Rev. 4/15
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal