Request to Drop an Anesthesia Permit

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Email *

Dentist Name *

Dentist License Number *

Level of Sedation to be dropped *

Reason *

I attest, I'm submitting this request on my own regard. I also acknowledge that if this notification is not received at least 90 days of my license expiring I will be prompted to pay the additional $10 in addition to the timely renewal fee and/or any late fees, if applicable.

Electronic Signature *

A copy of your responses will be emailed to the address you provided.

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