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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*

*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.