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.
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@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 $377 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 18 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.)

Forms 4 and 4A - For Endorsement Applicants Only

Form 4 - Personal Affidavit of Professional Practice for Endorsement Applicants (PDF 11 KB)
Only applicants who have not completed an approved residency program of at least one year's duration, are licensed in another jurisdiction and are seeking licensure by endorsement are required to complete this form.

Complete this form and send it to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 5.

Form 4A - Supporting Affidavit of Professional Practice for Endorsement Applicants (PDF 12 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.

If you are seeking licensure by endorsement, complete items 1-4 of this form. Give the form to a dentist(s) licensed and in good standing in the jurisdiction(s) in which you are currently licensed to complete. The form must be submitted directly by the licensed dentist 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. Please photocopy the form as needed.

Form 4B - Certification of Completion of Clinical Residency Program (PDF 22 KB)
This form must be submitted directly by your residency program director. 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 residency program director. Be sure to sign and date item 6.
  • Section II: The residency program director of the residency 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. This form cannot be submitted prior to the official date of completion of the residency program.
 
Form 5 - Application for Limited Permit (PDF 30 KB)

As of January 1, 2010, dental residents in programs approved by the Commission on Dental Accreditation of the American Dental Association are no longer required to obtain a limited permit in order to practice in the residency program. Residents are required, however, to register annually with the Department and pay an annual fee of $105.00. Residents should contact the program’s residency director regarding the registration procedures.

  • Section I: If you are applying for a limited permit, complete this section before having your prospective employer complete Section II or III, whichever is applicable. Your signature on Form 5 must be notarized by a Notary Public.
  • Section II: If you are requesting the limited permit for instructing in dentistry, have your prospective employer complete Section II.
  • Section III: If you are requesting the limited permit for an approved dental residency, have your prospective employer complete Section III.

Return the completed form with the $105 fee to the Office of the Professions at the address at the end of the form. If you did not complete the required coursework or training in the identification and reporting of child abuse as part of a New York State educational program, you must submit a certificate of completion from an approved provider or an exemption form (Form 1CE).

Remember that you must have your dental school submit a Certification of Professional Education (Form 2) before your limited permit application can be evaluated.

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.


Application to Request an Exemption from the Cardiopulmonary Resuscitation (CPR) Requirement (PDF 40 KB)

This form is not for all applicants. Use this form only if you are physically incapable of performing CPR.

As of January 1, 2009, all dentists must receive and maintain certification in cardiopulmonary resuscitation (CPR). If a dentist is physically unable to perform CPR, he or she may request an exemption by submitting an application for exemption. The request must be accompanied by a statement from the professional treating the disability and a signed assurance naming another individual or individuals who will maintain CPR certification and be present in the office while the exempt dentist is seeing patients.

Dental Residency Forms

Form 5R- Residency Director's Roster (PDF 17 KB)
Only for use by directors of residency programs approved by the Commission on Dental Accreditation of the American Dental Association, this form is to be submitted within 60 days after the start of a resident’s program. Attached to this form should be an individual check for each eligible resident made payable to the New York State Education Department in the amount of $105. The fee is payable annually for each academic year of the duration of the program as approved by CODA.
Child Support Obligation Disclosure (PDF 11 KB)
This form must be completed by each resident and submitted with the Residency Director’s Roster.

Dental Anesthesia Forms

Form 1 - Application for Dental Anesthesia/Sedation Certification (PDF 32 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@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 certification must complete this form and submit it with the $100 certification fee and a copy of your valid course completion card in either advanced cardiac life support (general anesthesia and parenteral conscious sedation applicants) or basic life support (enteral conscious sedation applicants) to the Office of the professions at the address at the end of the form. 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.

Forms 2 A, B and C - Verification of Program Completion

Use Form 2A to apply for a Dental General Anesthesia Certificate.
Form 2A - Verification of Approved Post-Doctoral/Graduate Level Education in Anesthesia or Education in Approved Specialty Program or Residency (PDF 23 KB)

Use Form 2B to apply for a Dental Parenteral Conscious Sedation Certificate.

Form 2B - Verification of Post-Doctoral Education in Use of Parenteral Conscious Sedation (PDF 27 KB)
 
Use Form 2C to apply for a Dental Enteral Conscious Sedation Certificate.
Form 2C - Verification of Pre-Doctoral or Post-Doctoral Education in Use of Enteral Conscious Sedation (PDF 27 KB)

The form appropriate to the type of certification you are requesting must be completed and submitted by the institution where you met the requirement. The Office of the Professions will not accept the form if it is submitted by the applicant.

  • Section I: Complete this section of the form before sending it to the educational institution. Be sure to sign and date item 8 and include any fee required by the institution.
  • Section II: The Registrar or appropriate official must complete this section and return the form directly to the Office of the Professions at the address at the end of the form.
Last Updated: April 7, 2014