Supervising Dentist Affidavit

By Section 1220.245 of the Rules for the Administration of the Dental Practice Act of the State of Illinois, a dental assistant must be at least 18 years of age with 1000 hours of clinical dental assisting experience or have graduated from a dental assisting program accredited by the Commission on Dental Accreditation of the American Dental Association, or be certified as designated by the Dental Assisting National Board, Inc to perform Coronal Polishing and Application of Pit and Fissure Sealants.

I, , attest that meets or

will meet the above criteria to attend the above courses on / /

Illinois License #

Note: This form must be returned to the American Dental Academy before or the participant will not be able to attend this course.