Dental Hygiene Anesthesia Form 1 - Dental Hygiene Restricted Local Infiltration Anesthesia/nitrous Oxide Analgesia Certification - Application For Certification & First Registration

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Dental Hygiene Restricted Local Infiltration
The University of the State of New York
Department Use Only
THE STATE EDUCATION DEPARTMENT
Anesthesia/Nitrous Oxide Analgesia Certification
Office of the Professions
Form 1
Division of Professional Licensing Services
Application for Dental Hygiene Local Infiltration Anesthesia/Nitrous
Oxide Analgesia Certification and First Registration
Applicants Must Complete Both Pages Of This Application In Ink
All applicants for certification must complete this form and submit it with the $25 certification fee
1
84
$25
ER
directly to the Office of the Professions at the mailing address at the end of Form 1. Make checks
payable to the New York State Education Department. NOTE: Your cancelled check is your receipt.
NYS License Number
You must answer all questions and provide all information requested unless otherwise indicated. Failure
to complete all required parts of the application will delay its review. You must sign and date the
Affidavit on this form in the presence of a Notary Public.
Date Issued
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Initials
3
Month
Birth Date
Day
Year
6
Telephone/E-Mail Address
4
Print Your Name Exactly As It Appears On Your Dental Hygiene License
Daytime Phone:  Home or  Business
Last
Area Code
Phone Number
First
E-Mail Address (Please print clearly):
Middle
 Home or  Business
Licensee business address, phone and e-mail address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
5
Mailing Address:  Home or  Business
(You must notify the Department promptly of any address or name changes.)
7
New York State DMV ID Number
(Driver or Non-Driver ID)
Line 1
Line 2
(Leave this blank if you do not have a
Line 3
New York State DMV ID Number)
City
State
Zip Code
Country/
Province
8
Name on New York State dental hygiene license: _______________________________________________________________________________
License number: _____________________________ Registration expiration date: _______ / _______ / _______
mo.
day
yr.
9
I have met the education and training requirements by (check one):
Completing an educational program provided by a New York State dental hygiene or dental school that is registered by the New York State
Education Department and includes the required 30 hours of didactic and 15 hours of clinical training.
at: ________________________________________________________________________________
____________________________
Institution
Completion date
Completing an equivalent educational preparation, acceptable to the New York State Education Department, offered by an institution that has
programs leading to licensure in dentistry and/or dental hygiene that are accredited by an acceptable accrediting body. The education must
include the required program content.
at: ________________________________________________________________________________
____________________________
Institution
Completion date
10
Name as it appears on degree or other credentials (if different from above): __________________________________________________________
Dental Hygiene Anesthesia Form 1, Page 1 of 2, Rev. 10/15

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