License Application Forms for Restricted Dental Faculty License

All applicants for licensure must initially submit Form 1 along with the $645 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.

This form must be submitted directly by the educational institution(s) you attended. The Office of the Professions will not accept this form if submitted by the applicant.
 

• Section I: Complete this section before sending the entire form to your school. Be sure to sign and date item 9.
• Section II: The Registrar must complete this section and return both pages of the form in an official school envelope with requested documents directly to the Office of the Professions at the address at the end of the form.

A transcript of all courses taken at the dental school and grades received must be attached for all graduates of non-registered or non-accredited programs. Additionally, the school must attach a transcript of all courses convalidated or accepted for transfer credit and the basis on which these subjects were convalidated, including the name of the institution from which credit was transferred. When studies were completed at more than one school, official records need to be sent to the Department from each school. Please photocopy the form as needed.

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 or Canada 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***.

Note: Do NOT use the email above 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.

*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.

Complete this form if you hold, or ever held, a license or certificate to practice any profession* in any jurisdiction.

This form must be submitted directly by the licensing/certifying authority. The Office of the Professions will not accept this form if submitted by the applicant.

• Section I: Complete this section before sending the entire form to the licensing/certifying authority of each jurisdiction in which you are or have been licensed/certified. Be sure to sign and date item 8.
• Section II: The licensing/certifying authority must complete this section, sign, date and return both pages of the form directly to the Office of the Professions at the address at the end of the form.

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..

*Profession is defined as professional titles licensed under New York State Education Law. 

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 or Canada 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.

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.

 

• Section I: Complete this section before sending the entire form to a dentist licensed and in good standing in the jurisdiction in which you practiced. Be sure to sign and date item 6.
• Section II: A dentist licensed and in good standing in the jurisdiction in which you practiced must complete the form and submit it directly 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 within the last five years. Please photocopy the form as needed.

This form must be submitted directly to the Office of the Professions by the director of an advanced education program in general dentistry or in a dental specialty, provided such program is accredited by an organization accepted by the Department. The Office of the Professions will not accept this form if submitted by the applicant.

 

• Section I: Complete this section before sending the entire form to the program director of the advanced education program you completed. Be sure to sign and date item 6.
• Section II: The program director of the advanced education program you completed must complete this section and return both pages of the form directly to the Office of the Professions at the address located at the bottom of the form.

 

This form must be submitted directly by the Dean of the school where you are employed as a full-time faculty member. The Office of the Professions will not accept this form if submitted by the applicant.

 

• Section I: Complete this section before giving the entire form to your Dean. Be sure to sign and date item 6.
• Section II: The Dean of the school where you are employed as a full-time faculty member must complete this section and return both pages of the form directly to the Office of the Professions at the address located at the end of the form.

NOTE: This form is required for initial licensure and, once you are licensed, must be submitted yearly.

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.

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 and reporting of child abuse because your practice does not involve professional contact with persons under the age of 18 and persons 18 or older with a handicapping condition who reside in a residential care school or facility.