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G Application for a Local Anesthesia Permit NAME: HOME ADDRESS: CITY, STATE & ZIP: HOME PHONE: EMAIL ADDRESS: ARKANSAS DENTAL LICENSE #: DATE ISSUED: WHERE COURSE TAKEN: WHEN COURSE TAKEN: EMPLOYER: LICENSE #: OFFICE ADDRESS: CITY, STATE & ZIP: OFFICE PHONE #: With the application, enclose the following: 1. Proof of successful completion of a local anesthesia course sponsored by or held in an ADA accredited dental hygiene/dental school. This proof must be either a copy of a certificate f.

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