Certification Of Clinical Practice Form
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1
2Licensure Without Further Examination
Form 001
CERTIFICATION OF CLINICAL PRACTICE
List all locations at which you practiced to verify the 3,500 hours of licensed clinical practice in the five
years immediately preceding this application (Dentists OAR 818-021-0011, Dental Hygienists OAR
818-021-0025). Use additional sheets if necessary.
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
Location/Address: __________________________________________________________________
__________________________________________________________________________________
Average hours per week __________________
_____ years _____months
From _______________________ to _____________________ TOTAL HOURS ________________
I certify that the above information is true and correct.
Applicant’s Signature ____________________________________________ Date ________________
Revised 03/2008
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Parent category: Business