Dental Hygiene Form 3 - Certification Of Licensure - The State Education Department
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1
2FORM 3
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
DENTAL HYGIENIST
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
CERTIFICATION OF LICENSURE
ALL APPLICANTS LICENSED IN OTHER JURISDICTIONS MUST COMPLETE THIS FORM FOR EACH JURISDICTION.
APPLICANT INSTRUCTIONS
1. Complete Section I in ink. Be sure to enter your name as it appears on your Licensure Application (Form 1) and sign and date item 8.
2. Send this form to the appropriate licensing authority of each jurisdiction in which you are or have been licensed as a dental hygienist as directed
in the instructions. Be sure to include any fee required.
SECTION I: APPLICANT INFORMATION
BIRTH DATE
1
2
SOCIAL SECURITY NUMBER
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT FULL NAME
Last
First
Middle
MAILING ADDRESS
4
You must notify the Department promptly of any address or name changes.
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
If you took a licensing examination in the United States using a different name, enter that name below:
Last ___________________________________________ First _____________________________________ Middle ______________________
6
If licensed by examination in the United States, indicate state or territory:_______________________________________________________
Date license was issued: ______________________________ License number: _______________________________
7
Have you taken the North East Regional Board (NERB) examination?
YES
NO
If yes, give all dates you have taken the examination ____________________________________________________________________
8
I request and give my permission to the licensing authority to complete the information on this form and send any documentation
requested, including that requested on this form, to the New York State Education Department.
Applicant's signature:
Date:
/
/
____________________________________________________________________
_______
_______
_______
mo.
day
yr.
FORM 3, PAGE 1 OF 2
February 2004
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