Dental Hygiene Restricted Local Infiltration Anesthesia/nitrous Oxide Analgesia Certification Form 2 - Verification Of Education
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1
2The University of the State of New York
Dental Hygiene Restricted Local Infiltration
THE STATE EDUCATION DEPARTMENT
Anesthesia/Nitrous Oxide Analgesia Certification
Office of the Professions
Form 2
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
VERIFICATION OF EDUCATION
APPLICANT INSTRUCTIONS
1.
Complete Section I. Enter your name as it appears on your certification application Form 1. Please be sure to sign and date item 8.
2.
Send this form to the institution you attended and request that the Registrar complete Section II. Be sure to include any fee required by the institution.
3.
The Registrar or other official that completes Section II must send this form directly to the Office of the Professions in a sealed school envelope. It will
not be accepted if submitted by the applicant.
SECTION I: APPLICANT INFORMATION
1
2
3
SOCIAL SECURITY
BIRTH
NUMBER:
DATE:
New York State Dental Hygiene
mo .
day
yr.
(Leave this blank if you do not have a U.S. Social Security Number)
License Number
4
PRINT YOUR FULL NAME EXACTLY AS IT APPEARS ON YOUR CERTIFICATION APPLICATION (FORM 1)
Last
First
Middle
5
MAILING ADDRESS (You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
Print name under which program was completed: __________________________________________________________________
7
Name of Institution: __________________________________________________________________________________________
Dates of attendance:
from __________ / __________ / __________ to __________ / __________ / __________
mo.
day
yr.
mo.
day
yr.
8
I request and give my permission to the institution listed in item 7 above to complete the information on this form and send any
documentation requested by the NYS State Education Department including that listed on page 2 of this form (e.g. an official
transcript) to the New York State Education Department.
Applicant's signature: __________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
September 2003
FORM 2 PAGE 1 OF 2
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