Form 5CS - Certification of Supervisor for Limited Permit

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.