To apply for certification to administer local anesthetics by block or infiltration

techniques:

1. hold a valid dental hygiene license issued or renewed by the Board on or after

_________________________

2. submit a certificate of completion from a dental hygiene program that was

completed within _________ years prior to the date of the application

3. a dental hygienist licensed in North Carolina or any other state or territory who has

been practicing dental hygiene for the two years

4. ...
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