For a downloadable version of the Recertification Application Template, please click here. Name (required) Home Address Work Address Office Phone Fax Your Email (required) Current Certificate Number Date of Expiration Have there been any restrictions to any dental licenses/general anesthesia permits since your last application to the ADBA? YesNo Describe: Record of Continuing Education American Society of Dentist Anesthesiologists Annual Meeting (please list the year and hours for each meeting) American Society of Dentist Anesthesiologists Review Course (please list the year and hours for each meeting) American Dental Society of Anesthesiology Scientific Meetings (please list the course title, month/year and hours attended for each meeting) ADSA State Component Meeting (please list the course title, month/year, state, and hours attended for each meeting) International Anesthesia Research Society and affiliates; American Society of Anesthesiologists and affiliates. (please list the course title, sponsoring organization, month/year and hours attended for each meeting) Other Continuing Education Courses (please list the course title, sponsoring organization, month/year and hours attended for each meeting). Lecture Presentations (up to 24 hours); Media Based CE (up to 48 hours); Grand Rounds (up to 48 hours) Total Hours I have successfully completed Basic Life Support for Health Care Professional and Advanced Cardiac Life Support courses within in the past two years. Credit Hours for BLS and ACLS may NOT be included in your recertification hours. YesNo I certify that the above information is accurate to the best of my knowledge and that I have made no false or misleading statements. I understand that inaccurate information will invalidate my application and that false or misleading information will disqualify me from this or any future applications to the ADBA. I understand and agree that submission of this application authorizes the ADBA, its officers and agents to take whatever steps are necessary to authenticate and verify the information provided on this application. The costs for recertification are included in your annual registration fees.