Certified Dental Assisting Form 5 - Application For Limited Permit
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Department Use Only
The University of the State of New York
Certified Dental Assisting
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 5
Division of Professional Licensing Services
Application for Limited Permit
1. A limited permit authorizes an individual to practice certified dental assisting under the direct
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$40
PR
1
personal supervision of an licensed dentist. Complete Section I. It is your responsibility to
ensure that the supervisor fully completes Section II.
Date Approved/Rejected
2. You may apply for a limited permit either at the same time as or after submitting an
application for a license as a certified dental assistant in New York State. If you have not yet
filed an Application for Licensure (Form 1), and the $103 fee for licensure and first
Permit Number
registration, you must submit them with this form and the $40 limited permit fee. Additionally,
evidence of satisfactory education using the Certification of Professional Education (Form 2)
must be submitted by your educational institution. Permits cannot be issued until all required
Date Issued
documentation has been received and approved.
3. Submit this application and the $40 fee to the Office of the Professions at the address at the
end of this form.
Date Expires
4. The limited permit is valid for a period of one year from the date issued. The permit may be
renewed for one additional year at the discretion of the Department. To apply for a
renewal you must submit a new application for a limited permit and a fee of $40. You may
Initials
not begin practice until your limited permit has been issued.
5. If your supervisor changes during the one-year time period. You must reapply for a new
limited permit. No additional fee is required.
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Telephone/E-Mail Address
Section I: Applicant Information
Daytime phone
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Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Area Code
Phone
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Birth Date
Month
Day
Year
E-mail Address
(please print clearly)
4
Print Name
If we may discuss your licensure
Last
using this e-mail address, please
check this box.
First
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Middle
I am applying for
Original permit
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Mailing Address
(You must notify the Department promptly of any address or name changes.)
Renewal of Original Permit
Line 1
Change of supervisor
Line 2
Line 3
City
State
Zip Code
Country/
Province
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Prospective Supervisor: _________________________________________________________________________________________
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Under the penalties of perjury, I declare and affirm that the statements made in the foregoing application are true, complete and correct.
Any false or misleading information in, or in connection with, any application may be cause for denial of permit and licensure.
__________________________________________________________________________
_________________________________
Applicant’s signature
Date
__________________________________________________________________________
Print name
Certified Dental Assisting Form 5, Page 1 of 2, Rev. 8/16
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