New York State Dental Residency
New York State Dental Residency Child Support Obligation Check only one:
The University of the State of New York THE STATE EDUCATION DEPARTMENT
Office of the Professions State Board for Dentistry op.prof/dent/
F I am not under an obligation to pay child support F I am under an obligation to pay child support and I am current with my child support obligation. F I am under an obligation to pay child support and I am not current with my child support obligation. (Attach explanation)
I declare and affirm that the statements made in this application, are true, complete and correct.
____________________________________________________________________________ _______________________________
Signature of Applicant
Date
____________________________________________________________________________ Print Name
____________________________________________________________________________ Notary Public
April 2011
New York State Dental Residency Child Support Obligation Check only one:
The University of the State of New York THE STATE EDUCATION DEPARTMENT
Office of the Professions State Board for Dentistry op.prof/dent/
F I am not under an obligation to pay child support F I am under an obligation to pay child support and I am current with my child support obligation. F I am under an obligation to pay child support and I am not current with my child support obligation. (Attach explanation)
I declare and affirm that the statements made in this application, are true, complete and correct.
____________________________________________________________________________ _______________________________
Signature of Applicant
Date
____________________________________________________________________________ Print Name
____________________________________________________________________________ Notary Public
April 2011
New York State Dental Residency Child Support Obligation Check only one:
The University of the State of New York THE STATE EDUCATION DEPARTMENT
Office of the Professions State Board for Dentistry op.prof/dent/
F I am not under an obligation to pay child support F I am under an obligation to pay child support and I am current with my child support obligation. F I am under an obligation to pay child support and I am not current with my child support obligation. (Attach explanation)
I declare and affirm that the statements made in this application, are true, complete and correct.
____________________________________________________________________________ _______________________________
Signature of Applicant
Date
____________________________________________________________________________ Print Name
____________________________________________________________________________ Notary Public
April 2011
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