The University of the State of New York

Dentistry Form 5R THE STATE EDUCATION DEPARTMENT

Page 1 of _____
Office of the Professions

Division of Professional Licensing Services

www.op.nysed.gov

Dental Residency Registration Roster

Certification of Eligibility for Exempt Status as a Dental Resident

_______________________________________________________________________________________________________________
Name of residency program approved by the Commission on Dental Accreditation

_______________________________________________________________________________________________________________
Address of residency program

________________________________________________ ____________________________________________________________
Program Specialty Beginning and end date of program

Instructions
The residency director of a general or advanced specialty residency program approved by the Commissioner on Dental Accreditation
(CODA) shall certify to the State Education Department, Office of the Professions, those residents eligible to be considered exempt from
licensure pursuant to Education Law §6605(5).
Attached to this form should be an individual check for each eligible resident made payable to the New York State Education Department
in the amount of $105. The check number must be provided in the check number column to ensure the proper processing of the fee. The
fee is payable annually for each academic year of the duration of the program as approved by CODA.
This form should be submitted no later than sixty days following the start of a resident’s program. Forms may be submitted throughout the
academic year.
This form is intended only for submission by the residency director. Attach additional sheets as necessary.
All students with less than a 4-year U.S. or Canadian DDS/DMD must complete and submit a Dental Education Record Form, and
must request that their college or university mail Form 2 (Certification of Professional Education) directly to the Office of the
Professions with an official transcript.
Date Doctoral Degree 4 Year U.S. or
Social Security Date of Birth Institution Awarding the 4 year
ADA Check
Last Name, First Name in Dentistry Awarded Candadian
Number (mm/dd/yy) DDS/DMD
Accredited* Number
(mm/dd/yy) dental degree

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Dentistry Form 5R, Page 1 of 3, Rev. 3/18

_____________________________________________________________________________________________ Page _____ of _____
Name of residency program approved by the Commission on Dental Accreditation
4 Year U.S.
Date Doctoral Degree or
Social Security Date of Birth Institution Awarding the 4 year ADA Check
Last Name, First Name in Dentistry Awarded Candadian
Number (mm/dd/yy) DDS/DMD Accredited* Number
(mm/dd/yy) dental
degree

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Dentistry Form 5R, Page 2 of 3, Rev. 3/18

_____________________________________________________________________________________________ Page _____ of _____
Name of residency program approved by the Commission on Dental Accreditation
4 Year U.S.
Date Doctoral Degree or
Social Security Date of Birth Institution Awarding the 4 year ADA Check
Last Name, First Name in Dentistry Awarded Candadian
Number (mm/dd/yy) DDS/DMD Accredited* Number
(mm/dd/yy) dental
degree

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

Yes Yes

 No  No

*Note: If a resident has not graduated from an ADA accredited dental school, his or her educational qualifications must be reviewed by the
Department's Office of Comparative Education. Residents should not be considered exempt until this review is complete. This review
requires receipt of transcripts directly from the resident's home institution accompanied by a Certification of Professional Education (Form 2),
and should therefore be commenced as soon as possible after the resident has been selected for your program. Please access the
Department's Web site at www.op.nysed.gov for instructions regarding this process.

Based upon the instructions found at www.op.nysed.gov, each of the individuals above are eligible to be considered exempt from licensure
pursuant to Education Law §6605(5).

IN WITNESS WHEREOF, I hereunto set my hand and the seal of this school

This _____________________________ day of ____________________________ 20 __________

Signature of Residency Director: _____________________________________________________

Print or type name: ________________________________________________________________ (SEAL)

Telephone: _________________________________ Fax: _________________________________

E-mail: __________________________________________________________________________

Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Dentistry Unit, 89 Washington Avenue, Albany, NY 12234-1000
Dentistry Form 5R, Page 3 of 3, Rev. 3/18