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.
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