Dental Hygiene Form 2 - Certification Of Professional Education Page 2
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2SECTION II : CERTIFICATION OF EDUCATION
INSTRUCTIONS TO REGISTRAR:
Please complete Section II, 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. DO NOT return this form to the applicant. It will not be
accepted if it is incomplete or if it is returned by the applicant.
Name of applicant: __________________________________________________________________________________________________
1
2
Prior to matriculation in professional school, did the applicant obtain a high school diploma or a GED?
YES
NO
Did the applicant satisfactorily complete a course of study in dental hygiene registered as licensure-qualifying
YES
NO
3
by the New York State Education Department or accredited by the American Dental Association?
Date degree/certificate of graduation was awarded: _______________________________ List degree granted _________________________
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5
CERTIFICATION
NOTE:
Certification by the school is not acceptable unless dated after graduation.
I hereby certify that to the best of my knowledge and belief the information in Section II is a true statement of the record of the professional education of
the individual named on this form.
Signature of Registrar: _____________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print or type name: ____________________________________________________________
Title or official position: _________________________________________________________
Institution: ___________________________________________________________________
(INSTITUTION SEAL)
Address: ____________________________________________________________________
____________________________________________________________________________
Telephone number:
( _________________ ) __________________________________
Fax number:
( _________________ ) _________________________________
E-Mail: ______________________________________________________________________
RETURN DIRECTLY
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
TO:
Dental Hygiene Unit, 89 Washington Avenue, Albany, NY 12234-1000.
February 2004
FORM 2, PAGE 2 OF 2
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