Texas Dentist - Level II NOTARIZED AFFIDAVIT …

1 Texas Dentist - Level IINOTARIZED AFFIDAVIT FOR PROOF OF CLINICAL PRACTICEType or Print Applicant s Name: This AFFIDAVIT MUST NOT be completed by the applicant.*Please print neatly or type*I, , the undersigned, do of my own personal knowledge make thefollowing statements and declare them to be true. am a licensed health care professional and my profession is .2. My license number is issued by the state of . have known _____ for the last _____ consecutive (Must not be completed by the applicant) If currently employed by the Federal government,military, or a dental school, one AFFIDAVIT must be from the commanding officer or dean.

2 I am not arelative of the applicant, nor am I a third party observer. In addition, I certify that I resided inthe same geographic area as the applicant at the time the practice was conducted. I have directand personal knowledge that said applicant has engaged in the clinical practice of dentistry for aminimum of three years out of the five years immediately preceding his/her application to the StateBoard of Dental Examiners; OR, as a dental educator at a dental or dental hygiene schoolaccredited by the Commission on Dental Accreditation of the American Dental Association for aminimum of five years immediately preceding his/her application to the State Board of DentalExaminers. I have this knowledge of the applicant s clinical practice because: following address and telephone number is the most current and valid for me to be reached forfurther verification of any information relating to this AFFIDAVIT .

3 Address City State Zip Area Code Telephone Ext. Signed by my own hand and sworn to on this the SUBSCRIBED AND SWORN to before me this day of ,20 day of 20 Notary Signature of Affiant My Commission Expires INCOMPLETE affidavits OR affidavits NOT NOTARIZED CANNOT BE not return completed form to completed, NOTARIZED form to: PBIS 23460 N.

4 19 Avenue, Suite 225th Phoenix, AZ 85027