Dental Hygienist Application Forms

Dental Hygiene Restricted Anesthesia 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 installed on your computer. Download times and print quality will depend on your connection speed and printer.

Form 1 - Application for Licensure & First Registration ( 44 KB)

All applicants for licensure must complete this form and submit it with the $128 licensure and registration fee 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.

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 ( 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 ( 21 KB)

This form must be submitted directly by the educational institution you attended.

• Section l: Complete this section of the form before sending it to your school. Be sure to sign and date item 8.
• Section ll: The Registrar or appropriate school official must complete this section and return the form in a school envelope directly to the Office of the Professions at the mailing address at the end of the form.
  
  

Form 3 - Certification of Licensure ( 22 KB)

Use this form only if you are or have been licensed as a dental hygienist in another jurisdiction. This form must be submitted directly by the licensing authority.

• Section l: Complete this section of the form before sending it to the licensing authority of each jurisdiction in which you are or have been licensed as a dental hygienist. Please photocopy the form as needed.
• Section ll: The licensing authority must complete this section and return the form directly to the Office of the Professions at the address at the end of of the form. All questions must be answered. Attach additional 8 1/2" x 11" sheets, if necessary. If the licensing authority in the state in which you are or have been licensed will not verify your regional examination score on Form 3, you must ask the regional dental examiner to provide your scores directly to us.

The following two forms are for endorsement applicants only:

Form 4A - Personal Affidavit of Professional Practice for Endorsement Applicants ( 13 KB)

If you are seeking licensure by endorsement, complete this form and return it to the Office of the Professions at the mailing address on the form.

Form 4B - Verification of Professional Practice ( 20 KB)

If you are seeking licensure by endorsement, complete items 1-6 of this form. Be sure to sign and date item 6 and submit the form to a dentist(s) licensed and in good standing in the state(s) in which you are currently licensed who must complete Section 2 and submit the form directly to the Office of the Professions at the mailing 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. Please photocopy the form as needed.

Form 5 - Application for Limited Permit ( 17 KB)

• Section I: If you are applying for a limited permit, complete this section before having your prospective supervising dentist complete Section II. Be sure to sign and date item 9.
• Section II: Ask your prospective supervising dentist to complete this section.

Return both pages of the completed form with the $50 fee to the Office of the Professions at the address at the end of the form. If you have not already, you must submit the Application for Licensure (Form 1), the $128 fee for licensure and first registration, and have the school where you completed your dental hygiene professional education program submit the Certification of Professional Education (Form 2) before your application for a limited permit can be approved.

Form 1CE - Child Abuse Certification of Exemption Form ( 17 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 of child abuse and maltreatment because the nature of your practice excludes contact with children.

Dental Hygiene Restricted Anesthesia Forms

Form 1 - Application for Dental Hygiene Local Infiltration Anesthesia/Nitrous Oxide Analgesia Certification ( 27 KB)

All applicants for certification must complete this form and submit it with the $25 certification fee 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.

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.

Form 2 - Verification of Education ( 28 KB)

• Section I: Complete this section of the form before sending it to the institution. Be sure to include any fee required by the institution and sign and date item 8.
• Section II: The Registrar or other appropriate official must complete this section and return the form in a sealed school envelope directly to the Office of the Professions at the address at the end of the form.