Form 5r - Residency Director'S Roster Page 2
ADVERTISEMENT
1
2Date 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
Yes
Yes
No
No
*Note: If a resident has not graduated from an ADA accredited dental school, his or her educational qualifications must be reviewed by the
Department's Office of Comparative Education. Residents should not be considered exempt until this review is complete. This review
requires receipt of transcripts directly from the resident's home institution accompanied by a Certification of Professional Education (Form 2),
and should therefore be commenced as soon as possible after the resident has been selected for your program. Please access the
Department's Web site at for instructions regarding this process.
Based upon the instructions found at , each of the individuals above are eligible to be considered exempt from licensure
pursuant to Education Law §6605(5).
IN WITNESS WHEREOF, I hereunto set my hand and the seal of this school
This _____________________________ day of ____________________________ 20 __________
Signature of Residency Director: _____________________________________________________
Print or type name: ________________________________________________________________
(SEAL)
Telephone: _________________________________ Fax: _________________________________
E-mail: __________________________________________________________________________
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
Dentistry Form 5R, Page 2 of 2, Rev. 7/15
ADVERTISEMENT
0 votes
Related Articles
Related forms
Arizona Form 819 - Resident Distributor's Certification Of No Nonparticipating Manufacturer's Activity
Financial
Schedule K-1 (arizona Form 165) - Resident Partner's Share Of Adjustment To Partnership Income - 2011
Financial
Arizona Form 165 - Resident Partner's Share Of Adjustment 2003 To Partnership Income - 2003
Financial
Form 5r Draft - Wisconsin Revocation Of Election By An S Corporation Not To Be A Tax-option Corporation
Financial
Form 5r - Wisconsin Revocation Of Election By An S Corporation Not To Be A Tax-option Corporation
Financial
Form 5r - Wisconsin Revocation Of Election By An S Corporation Not To Be A Tax-option Corporation
Financial
Related Categories
Parent category: Legal