- 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.