Dental Hygiene Form 5 - Application For Limited Permit - The State Education Department
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1
2Department Use Only
The University of the State of New York
Dental Hygiene
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 5
Division of Professional Licensing Services
Application for Limited Permit
Applicant Instructions
51
$50
PR
1
A limited permit authorizes a dental hygiene program graduate to practice dental hygiene under
the direct personal supervision of a New York State licensed dentist before completing the license
Date Approved/Rejected
examination requirement.
A limited permit is valid for one year from the date issued. The Department can issue a renewal
Permit Number
for one additional year at their discretion.
You must file an Application for Licensure (Form 1), the $128 fee for licensure and first
Date Issued
registration, a Certificate of Professional Education (Form 2) certifying your completion of an
acceptable dental hygiene professional education program, this Application for a Limited Permit
(Form 5) and the $50 fee to receive a limited permit.
Date Expires
Complete Section I. It is your responsibility to ensure that your supervising dentist fully completes
Section II.
Initials
If your supervisor and/or location changes during the one year period, you must reapply for a new
limited permit. No additional fee is required.
6
6.
Telephone/E-Mail Address
Section I: Applicant Information
Daytime phone
2
2.
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Area Code
Phone
3
3.
Birth Date
Month
Day
Year
E-mail Address
(please print clearly)
4
4.
Print Name as It Appears on Your Application for Licensure (Form 1)
Last
First
Middle
7
I am applying for
Original permit
5.
5
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Renewal of Original Permit
Line 1
Change of supervisor
Line 2
Change of location
Line 3
City
State
Zip Code
Country/
Province
8
8.
Supervising Dentist: ____________________________________________________________________________________________
9
8.
Under the penalties of perjury, I declare and affirm that the statements made in the foregoing application are true, complete and correct.
Any false or misleading information in, or in connection with, any application may be cause for denial of permit and licensure.
__________________________________________________________________________ _________________________________
Applicant’s signature
Date
__________________________________________________________________________
Print name
Dental Hygiene Form 5, Page 1 of 2, October 2010
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