License Application Forms

Instructions for completing and submitting the forms required for licensure appear below. You may also need to submit additional information (for example, examination scores). Please refer to the license requirements link on the left for complete information regarding all requirements you must meet.

Note: All forms are in Adobe Portable Document Format (PDF). To view or print these documents, you will need to have the free Adobe Reader External Link Icon installed on your computer. Download times and print quality will depend on your connection speed and printer.
Complete Application Packet

All forms and instructions in a single PDF file - Restricted Dental Faculty License Application Packet (PDF 135 KB)


Form 1 - Application for Licensure (PDF 25 KB)


Important Notice: A New York State professional license is valid for life unless it is revoked, annulled, or suspended by the Board of Regents. To practice in New York State your professional license must be registered. If your registration has lapsed and you need to reregister, do not submit a Form 1. Instead, contact the Registration and Fees Unit to request a Delayed Registration Application by e-mailing: OPREGFEE@mail.nysed.gov, or by calling 518-474-3817 Ext. 410.  When e-mailing, be sure to include your profession, license number, address on record, new address (if changed), date of birth and the last 4 digits of your SSN.

All applicants for licensure must complete this form and submit it with the $645 licensure and first registration fee directly to the Office of the Professions at the address at the end of Form 1. Make checks payable to the New York State Education Department. NOTE: Your cancelled check is your receipt.

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. Your signature on Form 1 must be notarized by a Notary Public.

Address/Name Change Form - Optional ( PDF 20 KB)

You are required to notify us within 30 days of any name or address changes. Please read the instructions and complete the appropriate sections of this form.

Form 2 - Certification of Professional Education (PDF 17 KB)
This form must be submitted directly by the educational institution(s) you attended. The Office of the Professions will not accept this form if submitted by the applicant.
 
  • Section I: Complete this section before sending the entire form to your school. Be sure to sign and date item 9.
  • Section II: The Registrar must complete this section and return both pages of the form in an official school envelope with requested documents directly to the Office of the Professions at the address at the end of the form.

A transcript of all courses taken at the dental school and grades received must be attached for all graduates of non-registered or non-accredited programs. Additionally, the school must attach a transcript of all courses convalidated or accepted for transfer credit and the basis on which these subjects were convalidated, including the name of the institution from which credit was transferred. When studies were completed at more than one school, official records need to be sent to the Department from each school. Please photocopy the form as needed.

Form 3 - Verification of Other Professional Licensure/Certification (PDF 18 KB)

Complete this form if you hold, or ever held, a license or certificate to practice any profession* in any jurisdiction.

This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.

  • Section I: Complete this section before sending the entire form to the licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
  • Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

NOTE: A Form 3 is not required for licenses/certificates issued by the New York State Education Department.

*Profession is defined as professional titles licensed under New York State Education Law. (See page 2 of the Address/Name Change Form for a list of those titles.)

Form 4 - Affidavit of Professional Practice (PDF 18 KB)
This form must be submitted directly by the endorsing dentist. The Office of the Professions will not accept this form if submitted by the applicant.
 
  • Section I: Complete this section before sending the entire form to a dentist licensed and in good standing in the jurisdiction in which you practiced. Be sure to sign and date item 6.
  • Section II: A dentist licensed and in good standing in the jurisdiction in which you practiced must complete the form and submit it directly to the Office of the Professions at the address at the end of the form.

You may need to have more than one affidavit submitted for comprehensive certification of the required two years of professional practice within the last five years. Please photocopy the form as needed.

Form 4A - Certification of Completion of Advanced Education (PDF 17 KB)
This form must be submitted directly to the Office of the Professions by the director of an advanced education program in general dentistry or in a dental specialty, provided such program is accredited by an organization accepted by the Department. The Office of the Professions will not accept this form if submitted by the applicant.
 
  • Section I: Complete this section before sending the entire form to the program director of the advanced education program you completed. Be sure to sign and date item 6.
  • Section II: The program director of the advanced education program you completed must complete this section and return both pages of the form directly to the Office of the Professions at the address located at the bottom of the form.
 
Form 4B - Verification of Full-Time Employment (PDF 16 KB)
This form must be submitted directly by the Dean of the school where you are employed as a full-time faculty member. The Office of the Professions will not accept this form if submitted by the applicant.
 
  • Section I: Complete this section before giving the entire form to your Dean. Be sure to sign and date item 6.
  • Section II: The Dean of the school where you are employed as a full-time faculty member must complete this section and return both pages of the form directly to the Office of the Professions at the address located at the end of the form.

NOTE: This form is required for initial licensure and, once you are licensed, must be submitted yearly.

Child Abuse Certification of Exemption Form (PDF 40 KB)
This form is not for all applicants. Use this form only if you are applying for an exemption to the requirement to complete training or coursework in the identification and reporting of child abuse because your practice does not involve professional contact with persons under the age of 18 and persons 18 or older with a handicapping condition who reside in a residential care school or facility.
Last Updated: April 7, 2014