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Department Use Only

The University of the State of New York

Dentist

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Form 1

Division of Professional Licensing Services

Application for Licensure

Applicants Must Complete All Pages of This Application In Ink

All applicants for licensure must complete this form and submit it with the $377 licensure and first

registration fee directly to the Office of the Professions at the address at the end of this form. You

must answer all questions and provide all information requested unless otherwise indicated.

Failure to complete all required parts of the application will delay its review. You must sign and

50 $377

date the Affidavit on this form in the presence of a Notary Public.

NYS License Number

Social Security Number

(Leave this blank if you do not have a U.S. Social Security Number)

Date Issued

Birth Date

Month

Day

Year

Initials

Print Name

Last

Telephone/E-Mail Address

First

Middle

Daytime phone

  Home or  Business

Licensee business address, phone and e-mail address are public information. Failure to

indicate business or home on this form for each item will deem it public information.

Area Code

Phone

E-mail Address

(please print clearly)

Mailing Address:

  Home or  Business

(You must notify the Department promptly of any address or name changes.)

Line 1

Line 2

New York State DMV ID Number

Line 3

(Driver or Non-Driver ID)

City

State

Zip Code

(Leave this blank if you do not have a New

York State DMV ID Number)

Country/

Province

Name as it appears on degree or other credentials (if different from above): ________________________________________________

Yes

 No

Have you previously applied for New York State licensure in any profession?

If “yes”, in what profession(s)? _______________________________________________________________

Yes

 No

10. Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime

(felony or misdemeanor) in any court?

Yes

 No

11. Are criminal charges pending against you in any court?

12. Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of,

suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined,

Yes

 No

censured, reprimanded or otherwise disciplined you?

Yes

 No

13. Are charges pending against you in any jurisdiction for any sort of professional misconduct?

14. Has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges or have you ever

Yes

 No

voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures?

NOTE: If you answer "Yes" to any questions numbered 10-14, submit a letter giving a complete detailed explanation. Include

copies of any court records including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same

for each action. If the court can no longer provide documentation, you must request, from the court, a letter stating why they cannot

provide the documents.

Dentist Form 1, Page 1 of 4, Rev. 6/16

Dentist Form 1 - Application For Licensure - The University Of The State Of New York The State Education Department - 2016

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