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Form 4A - Supporting Affidavit of Professional Practice for Endorsement Applicants

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.