21 NCAC 16D .0104. APPLICATION

(a)  All applications for provisional licensure shall be made on the forms furnished by the Board at www.ncdentalboard.org.  No application shall be deemed complete that does not set forth all the information required relative to the applicant.  Incomplete applications shall be returned to the applicant.  Any applicant who changes his or her address shall notify the Board within 10 business days.  Applicants shall ensure that official transcripts of undergraduate college and dental school credits are sent in a sealed envelope to the Board office.

(b)  The nonrefundable application fee shall accompany the application, along with a photograph of the applicant taken within six months of the date of the application.

(c)  Applicants who are licensed in other states shall ensure that the Board receives verification of licensure from the board of each state in which they are licensed.

(d)  All applicants shall submit to the Board a signed release form and completed Fingerprint Record Card and other form(s) required to perform a criminal history check at the time of the application.  The form and card are available from the Board office.

(e)  All applicants shall include a statement disclosing and explaining periods, within the last 10 years, of any voluntary or involuntary commitment to any hospital or treatment facility, for observation, assessment or treatment for substance abuse, with verification demonstrating that the applicant has complied with all provisions and terms of any drug treatment program, or impaired dentists or other impaired professionals program.

 

History Note:        Authority G.S. 90-29.3; 90-41(a);

Eff. September 3, 1976;

Readopted Eff. September 26, 1977;

Temporary Amendment Eff. January 1, 2003;

Amended Eff. December 1, 2014; January 1, 2004.