Application Forms for Dental Hygienists

All applicants for licensure must initially submit Form 1 along with the $128 licensure and first registration fee. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Change Address or Name  - You are required to notify us within 30 days of any address or name changes. Please read the instructions to request this change.

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 Education Documentation

The Office of the Professions (OP) will accept official electronic transcripts and forms 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 documentation 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 education documentation 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.

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.

Note: A Form 3 is not required for licenses/certificates issued by the New York State Education Department. Also, If the certification/verification documentation provided by a U.S. jurisdictions contains the same information requested in the Form 3, completion of a Form 3 for that jurisdiction is not necessary. For certification/verification documentation that does not contain the same information, a Form 3 will need to be completed for that jurisdiction.

Electronic Verification of Licensure, Certification and/or Examination

The Office of the Professions (OP) will accept electronic verifications of licensure, certification and examination completion from other licensing authorities located in the United States provided that:

• OP can independently authenticate that the verification is received directly from the licensing authority.
• The applicant had no opportunity to directly access or alter the verification before it is sent or transmitted.
• Any licensing authority verification submissions should be made electronically to DPLSVerif@nysed.gov.*

*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.

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.

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.

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

• OP can independently verify that the documentation is received directly from the supervisor
• The applicant had no opportunity to directly alter the experience form before it is sent or transmitted.
• Any experience documentation submissions should be made electronically to DPLSExperience@nysed.gov*.

*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.

All applicants for a limited permit must initially submit Form 5 along with the $50 limited permit fee. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit along with your application.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Supervisors and/or Settings
If you change supervisors and/or settings, or you have to add or remove a supervisor or setting, after a permit is issued, you must obtain an amended permit using the Limited Permit Change Form. After changes are processed you will receive an amended permit. A fee is not required for an amended permit issued as a result of a change in supervisor or setting. You must also submit a Form 5CS - Certification of Supervisor for Limited Permit for each new supervisor you are adding (see Upload Additional Documentation above).

Use this form ONLY if you are applying/have applied for a New York State Limited Permit as a Dental Hygienist online.

• Section I: Complete this section.
• Section II: Your supervisor must complete this section before you can submit it to the Office of the Professions at the appropriate address at the end of the form. It is your responsibility to ensure your supervisor fully completes Section II. Failure to complete this form will delay its review.

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.

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 submit this form along with the $25 certification fee. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

• 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.