Form 5r - Residency Director'S Roster
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1
2The University of the State of New York
Dentistry Form 5R
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
Dental Residency Registration Roster
Certification of Eligibility for Exempt Status as a Dental Resident
_______________________________________________________________________________________________________________
Name of residency program approved by the Commission on Dental Accreditation
_______________________________________________________________________________________________________________
Address of residency program
________________________________________________
____________________________________________________________
Program Specialty
Beginning and end date of program
Instructions
The residency director of a general or advanced specialty residency program approved by the Commissioner on Dental Accreditation
(CODA) shall certify to the State Education Department, Office of the Professions, those residents eligible to be considered exempt from
licensure pursuant to Education Law §6605(5).
Attached to this form should be an individual check for each eligible resident made payable to the New York State Education Department
in the amount of $105. The check number must be provided in the check number column to ensure the proper processing of the fee. The
fee is payable annually for each academic year of the duration of the program as approved by CODA.
This form should be submitted no later than sixty days following the start of a resident’s program. Forms may be submitted throughout the
academic year.
This form is intended only for submission by the residency director.
All international students must complete and submit a Dental Education Record Form accompanied by a Certification of
Professional Education (Form 2).
Date Doctoral Degree
International
Social Security
Date of Birth
Institution Awarding Doctoral Degree
ADA
Check
Last Name, First Name
in Dentistry Awarded
Dental
Number
(mm/dd/yy)
in Dentistry
Accredited*
Number
(mm/dd/yy)
Program
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Dentistry Form 5R, Page 1 of 2, Rev. 7/15
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