Dental Hygienist Application Forms

Dental Hygiene Restricted Anesthesia Forms

Important Notice: DO NOT use Form 1 if you are already licensed in this profession in New York State. 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. To renew your registration online, visit www.op.nysed.gov/renewalinfo.htm. If your registration has lapsed, contact us to request a Delayed Registration Application, or call 518-474-3817 Ext. 570.

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Form 1 - Application for Licensure ( PDF 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 ( 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 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.

Electronic Transcript Service

The Office of the Professions (OP) will accept official electronic transcripts from educational institutions (i.e. colleges/universities) or designated third-party* transcript entities located in the United States provided that:

  • The transcript is the certified true and official academic record and the document does NOT have an expiration date**.
  • OP can independently verify that the transcript is received directly from the educational institution’s registrar or officially designated third-party.
  • If a third-party transcript provider is involved, it is clear that the educational institution has designated the third party as the official sole provider of its transcripts.
  • The applicant had no opportunity to directly access or alter the transcript before it is sent or transmitted.
  • Any educational institution transcript submissions should be made electronically to DPLSEduc@nysed.gov***.

*OP will only accept third-party submissions after we have determined that the arrangement between the educational institution and the third party is consistent with our security and verification standards.

**Transcript documents with expiration dates cannot be accepted. Expirations on links to the document are acceptable.

***Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

Form 3 - Certification of Licensure (PDF 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 (PDF 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 (PDF 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 (PDF 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 (PDF 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 (PDF 27 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 our customer services unit to request a Delayed Registration Application by e-mailing: op4info@nysed.gov, or by calling 518-474-3817 Ext. 570. 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 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 (PDF 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.
Last Updated: August 29, 2019