Section II: Supervisor’s Certification
Instructions to the Supervisor: By completing Section II, you are certifying that the applicant will be under your direct personal supervision
and that you are licensed and currently registered to practice dentistry in New York State. The applicant
may not begin practice until the limited permit has been issued.
Direct personal supervision means that the dentist in the dental office or facility, personally diagnoses the condition to be treated, personally
authorizes the procedure and, before dismissal of the patient, personally examines the condition after treatment is completed.
Applicant’s name: _________________________________________________________________________________________________
(Section I, item 4)
Name of supervising dentist: _________________________________________________________________________________________
New York State Dental license number: ______________________________________
Practice address(es): ______________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Certification
I certify that I am the supervisor of the applicant and that I will abide by the requirements of direct personal supervision described above.
Signature: ____________________________________________________________________
Date: _______ / _______ / _______
mo.
day
yr.
Print name: ___________________________________________________________________
Name of Office: ________________________________________________________________
Address:______________________________________________________________________
______________________________________________________________________
Telephone: ____________________________________________________________________
Fax: _________________________________________________________________________
E-mail: _______________________________________________________________________
Mail this form and appropriate fee to: New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY
12201. DO NOT SEND CASH. Make check or money order payable to the New York State Education Department.
Dental Hygiene Form 5, Page 2 of 2, October 2010