Dentist Form 1 - Application For Licensure - The University Of The State Of New York The State Education Department - 2016 Page 2

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15. List dates you have taken the National Board Dental Examination: _______________________________________________________
Please check only one of the following: Applying for licensure based on successful completion of a residency program approved by
16
an acceptable national accrediting body; such as the Commission on Dental Accreditation.
Applying for licensure by endorsement of a license held in another jurisdiction of the
United States.
15. Please print clearly giving an accurate record of your educational preparation below. YOU MUST COMPLETE ALL INFORMATION FOR
17
ALL SCHOOLS/COLLEGES/UNIVERSITIES ATTENDED AND DIPLOMAS AND/OR DEGREES RECEIVED OR YOUR APPLICATION
WILL BE CONSIDERED INCOMPLETE. 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: _______ / _______
or Date GED issued: _______ / _______
mo.
yr.
mo.
yr.
Postsecondary/Preprofessional Education
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.
Professional Education
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.
Yes
 No
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16. Do you now hold, or have you ever held, a license or certificate to practice any profession* in any jurisdiction?
If yes, list each license/certificate, state or jurisdiction and provide appropriate information in the columns below. A Form 3 must be
submitted for each license/certificate listed unless it is a license/certificate issued by the New York State Education
Department. See the Applicant Instructions on Form 3 for specific information about completing and submitting the form.
*Profession is defined as professional titles licensed under New York State Education Law.
Date License/Certificate
License/Certificate
Limitations
Professional Title
State or Jurisdiction
Issued
Number
On License/Certificate
Dentist Form 1, Page 2 of 4, Rev. 6/16

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