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Dental Board : forms_original

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Forms & Applications

 Updated on 4/30/2013
 Links marked with  are PDF. Download Adobe Acrobat Reader for viewing .pdf files
Initial Applications
Dentist (by NERB examination) Download
Dentist (by waiver of clinical examination) Download
Dentist - Limited Dental - Graduate of U.S. or Canadian Dental School Download
Dentist - Limited Dental - Graduate of Foreign Dental School Download
Dentist & Dental Hygienist- Teacher Download
Dentist - Dental Pediatric Fellow Download
Dental Hygienist (by NERB examination) Download
Dental Hygienist (by waiver of clinical examination) Download

Dental Radiation Technologist - (by waiver) Download
Dental Radiation Technologist - (by examination) Download
Qualified Dental Assistant - General Download
Qualified Dental Assistant - Ortho Download
Dentist Volunteer Application Download
Dental Hygienist Volunteer Application Download
Retired Volunteer Application Download
Dentist and Dental Auxiliary Personnel Volunteer application Download
Reactivation/Reinstatement
Reactivation (Dentist or Dental Hygienist or Teacher) Download
Reinstatement (Dentist or Dental Hygienist or Teacher) Download
Reinstatement Application  (Dental Radiation Technologist) Download
​Reinstatement Application of Expired 2013 (Dental Radiation          Technologist) Download
Renewals
Dentist Download
Dental Hygienist Download
Dental Radiation Technologist Download
Application for Recognition as a Specialist 
Application for Recognition as a Specialist Download
Complaint
Complaint Form Download
Sedation Permits
Instructions for Anesthesia and Sedation Application
Application for General Anesthesia & Parenteral Sedation Evaluators Download
Application for Initial Anesthesia and Sedation Permits and Certificates Download
Conversion- General Anesthesia/Parenteral Sedation Class II & III Download
Conversion- Parenteral Sedation Permit Class II- ADD'L APP Download
Miscellaneous Forms
​Photo Affidavit- All license types
Download
Change of Information (name, address, etc.) Download
Application for Corporate Name Download
​Drug Dispensing Application Form


Download
​Dental Hygiene Waiver of General Supervision
Download​
Monitor Nitrous Oxide (Not Out of State) Download
Monitor Nitrous Oxide (Out of State) Download
Application to Administer Local Anesthesia by Infiltration 
Applicant recognized to administer local anesthesia in another state
Download
Applicant not recognized to administer local anesthesia in another state
Download

BLOCK Application-Not Out of State
Download

BLOCK Application-Out of State
Download


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Table of Contents

Board Members

  • President -  Maurice S. Miles, D.D.S.
  • Vice President - Ronald F. Moser, D.D.S.
  • Secretary Treasurer - Jane Casper, R.D.H., M.A.
  • Executive Director - Laurie Sheffield-James