Dental Hygiene Form 2 - Certification Of Professional Education
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1
2FORM 2
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 PROFESSIONAL EDUCATION
REGISTERED OR ACCREDITED PROGRAMS
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 the
authorization in item 8.
2. Send this form to the institution where you completed a New York State registered licensure-qualifying or American Dental Association,
Commission on Dental Accreditation accredited dental hygiene program. Be sure to include any fee required by the school.
3. The institution which completes Section II must send this form directly to the Division of Professional Licensing Services at the address at the
end of this form. It will not be accepted if submitted by the applicant.
SECTION I: APPLICANT INFORMATION
1
2
SOCIAL SECURITY NUMBER
BIRTH DATE
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
Last
First
Middle
MAILING ADDRESS
You must notify the Department promptly of any address or name changes.
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print name under which degree or diploma was awarded: __________________________________________________________________
6
Postsecondary/Preprofessional institution attended: __________________________________________________________________
7
Professional school attended: _______________________________________________________________________________
Address: _______________________________________________________
Date diploma was awarded: _______ / _______ / _______
mo.
day
yr.
I request and give my permission to the institution named in item 7 above to complete the information on this form and send any documentation
8
requested, including that requested on this form (e.g. an official transcript), to the New York State Education Department.
Applicant's signature: _____________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
February 2004
FORM 2, PAGE 1 OF 2
CERTIFICATION BY INSTITUTION OFFICIAL IS TO BE MADE ON PAGE 2
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