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APPLICATION FOR DENTAL HYGIENE LICENSURE BY EXAMINATION

GEORGIA BOARD OF DENTISTRY

A Division of the Georgia Department of Community Health 2 Peachtree Street, N.W. 6th Floor Atlanta, Georgia 30303 gbd.

Please read the instructions carefully and be familiar with the laws and rules governing the practice of dental hygiene in the State of Georgia. Visit the following web site for information: gbd.

**Important**

The Board cannot process incomplete applications. If any item is missing, incomplete or incorrect, your application cannot be reviewed by the Board.

Please review this application before you submit it to ensure that all information and documentation is complete and correct.

Incomplete applications are maintained in the Board office for a period of one (1) year. After such time the application is rendered void and the applicant must reapply and pay all required fees.

Application Checklist The following checklist is an important part of your application. Please use this checklist

to ensure that you submit a COMPLETE application.

The $75 non-refundable application fee payable by check or money order to the Georgia Board of Dentistry must be included with your application.

returned for insufficient funds will be assessed a service charge pursuant to O.C.G.A. ? 16-9-20.

1. NOTARIZED APPLICATION: Completed application form accompanied by the appropriate fee. Your application will not be processed unless the fee and all supporting documents are received. If licensure is granted, the license will be required to be renewed by the last day of December in ODD numbered years, regardless of when you were originally licensed. The licensure process could take up to a minimum of 30 days after submission of a completed application. Plan your application time accordingly.

2. LICENSE VERIFICATION: Official licensure verification for every dental hygiene license ever held. Each verification must indicate the date of licensure, the licensure status (active, inactive, expired, revoked, etc.), any disciplinary actions taken against you by the licensing board and the result of these actions. The applicant must provide a certified copy of the formal complaint/pleading, outcomes, and a personal written explanation for each instance of discipline. You should call each state board about fees for these services. The verification must be submitted with your application IN THE ORIGINAL SEALED ENVELOPE FROM THE STATE BOARD, and must be dated within four months of Board receipt of your complete application packet.

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3. DEGREE TRANSCRIPT: An official transcript which documents graduation with an A.S., B.A., or B.S. degree from a dental hygiene school which is accredited by the American Dental Association (ADA) Commission on Dental Education. The transcript must be IN THE ORIGINAL SEALED ENVELOPE FROM THE COLLEGE. Georgia laws ?? 43-11-71 and 43-11-71.1 require graduation from an ADA-accredited school.

4. NATIONAL BOARD SCORES: National Board Dental Hygiene Examination Scores (NBDHE) from the ADA Joint Commission on National Dental examinations. The ADA will no longer send results via mail. You may access your national board results online by going to . Download your results and submit with your application. If you have any issues accessing this information, please contact the ADA at 800-232-1694 or nbexams@.

5. CLINICAL LICENSURE EXAMINATION: Proof of having successfully passed a clinical licensure examination. Effective January 1, 2006, each candidate must pass all sections with a score of 75 or higher on the examination administered by the board or by any testing agency designated and approved by the Board. The testing agency currently approved by the board is the Central Regional Dental Testing Services (CRDTS) ? or 785-273-0380. Submit a certified copy of your examination score sheet.

The board will accept SRTA examination scores of 75 or higher if attained between February 22, 1993 and December 31, 2005. SRTA retake examination results will be accepted until December 31, 2006.

6. JURISPRUDENCE EXAMINATION: Successful completion of the Jurisprudence Examination with a score or 75 or higher. The Jurisprudence examination may be taken as an open book exam. The examination and "law and rules" governing the practice of dentistry in Georgia may be obtained on the Georgia Board of Dentistry website at: gbd.. Score is only valid for one (1) year.

7. NATIONAL PRACTITIONER DATABANK: Submit a sealed self-query from the NPDBHIPDB, please visit npdb. or call the Customer Service Center at 1-800767-6732.

If the National Practitioner Data Bank (NPDB) report provides any disciplinary action, certified copies of any pending or final disciplinary actions or malpractice actions against applicant must be submitted. All applicants must submit a NPDB report along with the completed application. The NPDB report must be dated within four months of the submission of the application. The ONLY applicants exempt from the requirement of NPDB report submission are those applicants within 6 months of dental school graduation and have never been issued a dental license in any state or U.S. territory.

The NPDB report must be received in the ORIGINAL SEALED ENVELOPE FROM NPDB. Applicants who have disciplinary or malpractice case(s) (open & closed) will be considered for licensure on a case- by-case basis, after receipt of all required application materials. For each case, the applicant must submit: 1) A copy of the formal complaint pleadings filed by the plaintiff/complainant or State Regulatory Agency,

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2) A copy of the final action, disposition, or settlement, 3) A personal explanation of the disciplinary action or the malpractice claim, and 4) Any further information requested by the Board in separate communications. 8. CPR: A photocopy of your current CPR certification in compliance with Board Rule 1505-.04. 9. Copy of Court Document or Affidavit explaining any discrepancies of the applicant's name if documents submitted bear different name(s). [i.e. marriage certificate, divorce decree, legal name change] 10. EXPEDITED APPLICATION REVIEW: Military spouses, service members, and transitioning service members qualify for expedited application review and should review Board Rule 150-7-.06 for details. 11. TEMPORARY LICENSURE: If applying for temporary licensure please follow ALL instructions listed on form. Relocation: - If you relocate during the time that your application is being processed, you must notify the Board of your new address in writing by fax to (470) 386-6124 or mail. This will enable you to receive Board correspondence.

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Do Not Write In This Section: Receipt#: ___________ Amount: ___________ Applicant #: __________ Initials/Date: ______________

GEORGIA BOARD OF DENTISTRY

Address: Telephone #: Fax #: Website:

2 Peachtree Street, N.W., 6th Floor, Atlanta, GA 30303 (404) 651-8000 (470) 386-6124 gbd.

Application For: Dental Hygiene License By Examination Application $75 Non-Refundable Fee

Checks returned for insufficient funds will be assessed a $40 service charge pursuant to O.C.G.A. ? 16-9-20

DISABILITY- If you have a disability and may require an accommodation, you must contact the Board to obtain the REQUEST FOR DISABILITY ACCOMMODATIONS GUIDELINES. VETERANS PREFERENCE POINTS- Veterans may be eligible for special benefits in testing. For more information, contact the Board office. Submit copy of DD-214 with your application.

I am a military spouse, service member, or transitioning service member, and I am requesting expedited

application review. I understand that I may be required to submit a copy of my PCS orders, a copy of my

spouse's PCS orders and my marriage certificate, or other documentation as requested by the Board.

Yes

No

Part I: Personal Information

1. Name:______________________________________________________________________________________________

Last

First

Middle

Maiden

Name as shown on exam records or transcripts (if different)______________________________________________________

2. Social Security Number*: _________- _______-___________ 3. Date of Birth:______________

4. Physical Address: ____________________________________________________________________________________

(Street) (Apt. #) (City/State/Zip Code)

(P.O. Box is not acceptable)

5. Mailing address (if different):

______________________________________________________________________________________________________

(Street)

(Apt. #)

(City/State/Zip Code)

If you are granted a license, your name, mailing address and license number are public information. 6. E-Mail Address:________________________________________________

7. Telephone #: Home: ( )__________ Work ( )__________ Other ( )____________

8. Military Service: ________________

Dates of Service: ______________

Honorable/Dishonorable Discharge: ________________

*This information is authorized to be obtained and disclosed to state and federal agencies pursuant to O.C.G.A. ?19-11-1 and O.C.G.A. ?20-3-295, 42

U.S.C.A. ?551 and 20 U.S.C.A. ?1001. It may also be disclosed to the National Practitioner's Databank (NPDB) and the Healthcare Integrity and

Protection Data Bank (HIPDB) or other licensing boards, or other regulatory agencies for license tracking purposes.

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Part II: Professional Education

9. Highest Degree Earned: ____Doctorate ____Master ____Bachelor ____Associate _____Diploma/Certificate

10. Name/Address of Entry Level Professional Institution (e.g. technical school, undergraduate

college/university):_____________________________________________________________________________________

a. Dates Attended: __________________

c. Graduation Date: ___________________

b. Major: ____________________

d. Degree(s) Earned: __________________

11. Name/Address of Graduate School/University:_____________________________________________________________

a. Dates Attended: __________________

c. Graduation Date: ______________________

b. Major: _____________________

d. Degree(s) Earned: _____________________

12. Name/Address of Post-Graduate School/Hospital (if applicable): ______________________________________________

a. Type of Training: ___________________________

b. Dates Attended: ___________________

13. National Board Information: I hereby give permission for staff of the Georgia Board of Dentistry to verify my national board scores through the ADA Hub. My DENTPIN # is________________________. I understand the result information made available through the ADA Hub is intended for use in making licensure decisions. It is not to be used for other purposes or shared with any group or individual outside of the Georgia Board of Dentistry.

__________________________________________ Signature of Applicant

14. National Practitioners Data Bank/Healthcare Integrity and Protection Data Bank: The Georgia Board of Dentistry requires all candidates for licensure to query the NPDB/HIPDB before licensure will be granted: You may contact the NPDB/HIPDB by calling: 1-800-767-6732 or by submitting query online at: npdb.. When you receive the RESPONSE from the NPDB/HIPDB please forward the information to the Board office along with your completed application. If you are a recent graduate (within the past six months) and not licensed in any other state, you are exempt from this requirement.

15. Did you require special accommodations for any examination, SRTA, CRDTS, NERB, ADEX, WREB, or CITA as outlined in the Americans with Disabilities Act? Yes or No If yes, what accommodations were made? _____________________________________________________________________

16. Have you ever failed a portion of any clinical examination, CRDTS, NERB, ADEX, SRTA, WREB, CITA, or any other regional or state clinical examination? Yes No If yes, give dates (list regional or state if applicable).

_____________________

___________________ ___________________ ______________________

If you've failed this exam three (3) or more times please request an exam history from CRDTS, NERB, ADEX, SRTA, WERB, CITA or other regional or state board.

17. Since graduating from hygiene school and passing the clinical examination, has there been a gap in clinical experience in excess of three years?

Yes No If yes, please provide a written explanation.

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Part III:

If yes to any of the following questions you must attach a full written explanation pertaining to that particular question.

18. Do you presently have any contagious or infectious disease? Yes No

19. Have you ever had a formal complaint filed against you with any dental hygiene society, association, hospital, or dental board? Yes No

20. Has any state licensing board revoked or suspended your certificate/license, or taken other disciplinary action? Yes No

21. Have you ever voluntarily surrendered a dental hygiene license? Yes No

22. Have you ever had any malpractice suits filed against you? Yes No

23. Have you ever been denied issuance of or, pursuant to disciplinary proceedings, refused renewal of a license by any board or agency in Georgia or any other state? Yes No

24. Have you ever been denied the privilege of taking an examination before any Dental Board or licensing authority? Yes No

25. Have you ever failed an examination required of any Dental Board or other licensing authority? Yes No

26. Have you ever been refused, or suspended from membership in a dental hygiene society, or association, or hospital staff? Yes No

27. Have you ever personally used narcotics or alcohol excessively or have you ever undergone treatment for addiction to alcohol or other controlled substances or habit forming substances? Yes No

28. Are there any other facts not disclosed by your answers which may have a bearing on your fitness or eligibility to practice dentistry in Georgia and which should be placed at the disposal or brought to the attention of the State Board of Dentistry? Yes No

29. Have you ever been summoned, arrested, taken into custody, indicted, convicted or tried for, or charged with, or pled guilty to, or pled, nolo contender to, a violation of any law or ordinance or the commission of any felony or misdemeanor (excluding minor traffic violations), (DWI & DUIs' are not minor traffic violations), or have you been requested to appear before a prosecuting attorney or investigative agency in any matter? Yes No

(Although a conviction may have been expunged from the records by order of court, it nevertheless must be disclosed in your answer to this question). If yes, for each occurrence furnish a written statement giving the complete facts in your own words, including in such statement the date, name and nature of the offense, the name and locality of the court, and the disposition of each such matter. You must attach the court disposition.

30. Out of State Licensure Certification(s):

List all states which you have been issued a license to practice dentistry: (active, inactive, revoked, suspended, expired, lapsed etc.) You should have each state listed send an official letter of licensure verification/certification. See instruction

sheet for details. If not applicable check here: ( ) n/a and initial

STATE

DATE OF LICENSURE

LICENSE STATUS

_________________________

________________________ _____________________

_________________________

________________________ _____________________

_________________________

________________________ ______________________

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