Dental Hygiene Form 3 - Certification Of Licensure - The State Education Department (Page 2 of 2) in pdf

SECTION II : CERTIFICATION OF LICENSURE

INSTRUCTIONS TO LICENSING AUTHORITY:

Please complete this section, sign and date the certification and return this form directly to the

Division of Professional Licensing Services at the address at the end of this form. This form will not be accepted if returned by the applicant.

Name of applicant: ________________________________________________________________________________________________

Profession in which applicant is licensed in your state:

Dental Hygiene

Other: ___________________________

License number: _______________________________ Date of licensure: ___________________________________________

On what basis was the applicant licensed?

YES

Are charges pending against the licensee for professional misconduct, incompetence or negligence?

YES

Has the licensee ever been found guilty of such charges or surrendered a professional license?

If answer to question 5a or 5b is "yes," please attach a detailed description.

Please specify the state, national and/or regional examinations completed by the applicant ________________________________________

_________________________________________________________________________________________________________________

If the applicant was licensed in your state via a state constructed examination or a regional clinical examination, other than the North East

Regional Boards, please complete the following or attach a copy of the applicant's examination grade report.

Date of examination: _____________________________________________________________________________________________

Number of days of examination: ____________________________________________________________________________________

List of clinical subjects conducted on patient: __________________________________________________________________________

______________________________________________________________________________________________________________

List of simulated or written subjects: ________________________________________________________________________________

______________________________________________________________________________________________________________

Minimum passing grade in each subject is: ___________________________________________________________________________

NOTE: New York requires a minimum passing score of 75% in each subject area. If scores are not given in percent, please convert.

CERTIFICATION

I certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the applicant named on this form. I

further certify that, other than those listed above, this licensing authority has never taken any disciplinary action against this person and that, in so far as

the licensing authority has knowledge, there have been no charges preferred nor has any information been presented relating to any question of

unprofessional or immoral conduct except as noted in question 5 above.

Signature: ___________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Print name: __________________________________________________________________

Title: _______________________________________________________________________

Agency: ____________________________________________________________________

(SEAL OF LICENSING

AUTHORITY)

Address: ___________________________________________________________________