Dentist Form 2 - Certification Of Professional Education

Section II: Certification of Education

Instructions to Registrar: Please complete Section II and return both pages of this form directly to the New York State Education

Department at the address at the end of this form. This form will not be accepted if returned by the applicant.

Note: Non-registered or non-accredited programs must attach a transcript listing all courses taken by the applicant at the dental

school and grades the applicant received. Also, attach a transcript of all courses convalidated or accepted for transfer credit by

your dental school and the basis on which these subjects were convalidated, including the name of the institution from which

credit was transferred.

Name of applicant: ____________________________________________________________________________________________

(Section I, item 5)

Completed satisfactorily, prior to matriculation in professional school, at least sixty hours of satisfactory post-secondary study, including

courses in physics, biology or zoology, chemistry, and organic chemistry.

Yes

Name of college(s) in which pre-professional study was completed:

_____________________________________________________________________________________________________________

Date of applicant's entrance, date of completion of studies or withdrawal from the dental school*:

Entrance date: _______ / _______ / _______

Completion/withdrawal date: _______ / _______ / _______

mo.

day

yr.

mo.

day

yr.

Degree/diploma conferred: __________________________________________________ Date awarded: _______ / _______ / _______

mo.

day

yr.

Dental Program was ____________________ years or ____________________ months.

For schools outside the U.S.:

Did the program have a social service requirement for graduation?

Yes

If yes, give dates and name of institution/facility in which requirement was met.

Institution: ________________________________________________________ Dates from: _______________ to: _______________

mo./yr.

Dental school: ________________________________________________________________________________________________

Name of student as it appears on school records: ____________________________________________________________________

*For applicants for limited permits only, tentative completion dates may be accepted provided all requirements for graduation have been met.

Certification

I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the

professional education of the individual named on this form.

Signature of Registrar: ___________________________________________________________

Date: _______ / _______ / _______

mo.

day

yr.

Title or official position: __________________________________________________________

Institution: _____________________________________________________________________

Address: ______________________________________________________________________

(SEAL)

City: ____________________________ State ____________ Zip Code ____________________

Telephone: _______________________________ Fax: _________________________________

E-mail Address: _________________________________________________________________

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.

Dentist Form 2, Page 2 of 2, (Rev. 1/07)

Dentist Form 2 - Certification Of Professional Education - 2007 Page 2

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