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APPLICATION FOR DENTAL HYGIENE/ PROVISIONAL LICENSURE

MATERIALS TO BE SUBMITTED

(Retain this Sheet for Your Records)

The Board prefers that the materials listed below be submitted with your application; however, if needed, you may have the

materials sent directly to the Board office by another source. You are responsible for ensuring that the Board office receives the

required materials. It is not the Board’s responsibility to ensure that all items are received and that your application is complete.

It is recommended that you have items sent certified mail return receipt. A COMPLETED APPLICATION, LICENSE FEE AND

ALL REQUIRED MATERIALS MUST BE RECEIVED IN THE BOARD OFFICE PRIOR TO ISSUANCE OF A LICENSE.

It is your responsibility to review applicable statutes and rules to determine whether you are eligible to apply for this type of licensure!

1) Completed application – (Incomplete applications WILL BE RETURNED)

2) License fee - $75.00

Provisional Fee - $60.00 (This fee is to paid ONLY if you are getting a temporary provisional license)

CHECK OR MONEY ORDER ONLY (Payable to: NC State Board of Dental Examiners)

THIS FEE IS NON-REFUNDABLE!! The application fee is nonrefundable and non-transferable and shall not be returned

to you under any circumstances. This means that even if your application is denied, or you are offered a Consent Order by

the Board, or your petition the Board for a formal hearing, the application fee will NOT be refunded

“If your check is not paid on presentment or is dishonored, you agree to pay the amount allowed by state law. We may electronically debit or

draft your account for this charge. Also, if your check is returned for insufficient or uncollected funds, your check may be electronically re-

presented for payment.”

3) Dental Hygiene National Board Scores: A passing score is required before you will be issued a North Carolina license. Photocopies

are NOT acceptable. We can access scores electronically; please supply date and location taken.

Please note! You must request scores be sent in order for them to be uploaded for our access. National Board office: (312) 440-2678 or

http://www.ada.org/en/jcnde/examinations

4) Transcripts from high school or a high school equivalency certificate and transcripts from any colleges attended other than

dental hygiene (photocopies are acceptable).

5) An official transcript from your dental hygiene school must accompany this application in a sealed school envelope or sent

directly from the School’s Registrar’s office. Digital copies accepted if sent from the school via email to

[email protected]. The transcripts must contain the date of graduation and the degree received. DO NOT SEND

INCOMPLETE TRANSCRIPTS!! These should indicate your present name.

6) One (1) passport-size photographs (2” X 2”) glued to the application form. Photograph must fit the square on the

application!!

7) If you are or have ever been licensed in a health care related field (dental hygiene, nursing, etc.) in another state or

jurisdiction, you must have a Certificate of Licensure from the licensing Board of each state or jurisdiction. This form must

be received in a sealed envelope with your application or sent directly to the Board office via mail. Digital copies will be

accepted directly from the issuing State or jurisdiction via email to applications@ncdentalboard.org.

(Copies of your license

or renewal certificates are NOT acceptable.)

8) Applicants licensed to practice dental hygiene in another state/jurisdiction must submit a National Practitioner & HIPAA Data Bank

Report. Please contact the National Practitioner Data Bank at www.npdb-hipdb.hrsa.gov or 1-800-767-6732. When you receive the

report, please forward to the Board office unopened. We will accept a hard copy or an electronic copy of the report.

9) A signed release form, completed Fingerprint Record Card, an other such form(s) required to perform a criminal history

check at the time of application.

Instate applicants take attached forms to local law enforcement for LiveScan. Out of state applicants

email your mailing address to info@ncdentalboard.org to have card and forms mailed to you; do not use attached forms.

10) A letter from a supervising dentist. (Required for a provisional license only). Form letter may be obtained at

http://www.ncdentalboard.org/PDF/supervisingdentistletterDH.pdf.

Please contact the Board office if you have any questions regarding this application.

Address:2000 Perimeter Park Dr., Suite 160, Morrisville, NC 27560 • E-mail Address: [email protected]rg

Web Address: www.ncdentalboard.org • Phone Number: (919) 678-8223 • Fax Number: (919) 678-8472

**Please note that once your application is received by the Board office,

the process takes at least 90 days. Applications must be completed within 1 year or they become void and

the application process must begin again.**

ProcedureforFingerprinting

In‐StateapplicantsuseLiveScan

1. ApplicantfillsouttheElectronicFingerp rintS ubmissionReleaseofInformationForm,signsanddatesit.The

authorizedofficialatthenon‐criminaljusticeagencysignsanddatestheform,thenprintsthename,address

andphonenumber.Photoidentificationmustbechecked.

2. Applicanttakestheformtothelaw

enforcementagency.

3. Thelawenforcementagencyreviewstheformandchecksforaphotoidentification.

4. Thelawenforcementagencyrollstheprints andenterstheinformationfromtheform.Thefingerprintdatais

electronicallytransmittedtotheSBI.

5. Applicantreturnstheformwiththeirapplicationtothe

authorizedofficialattheiragency.

YoumustcallyourlocallawenforcementtodeterminetheparticipatingLiveScanlocation.Anyquestions

regardingLiveScanmaybedirectedto:

YvonneMatthews,[email protected],919.662.4509Ext6300

CindyCoats,[email protected],919.662.4509Ext6366

MonicaParker,[email protected],919.662.4509Ext6397

Out‐of‐Stateapplicantsmustemailtheirmailingaddressto[email protected]sothatwecanmailthe

appropriatefingerprintcard/releaseforms.Takethecardtoyourlocallawenforcementagencyandfollow

theinstructionsforfingerprinting.CompletedfingerprintcardANDreleaseformsmustaccompanyyour

applicationforlicensure.

NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS

APPLICATION FOR

DENTAL HYGIENE/PROVISIONAL LICENSURE

PLEASE TYPE OR PRINT LEGIBLY

Each question must be answered fully, truthfully and accurately. All supporting data requested must

accompany this application. If the space for any answer is insufficient, you must complete your answer on a

rider signed by you, specifying the number of the question to which it relates and enclosing it with this

application. DO NOT SEPARATE THIS FORM AND DO NOT STAPLE ENCLOSURES TO THIS

APPLICATION!

It is the responsibility of each applicant to review applicable statutes and rules to determine eligibility for

licensure prior to applying for a North Carolina Dental or Provisional license. Statutes and rules are

available on the Board’s website or by calling (919) 678.8223.

I am making application for a license based on the clinical examination held ______________________,

a legal requirement to determine my qualifications to practice dental hygiene in the State of North Carolina.

1. ____________________________________________________________________________________

(First Name in Full) (Middle/Maiden) (Last Name in Full)

____________________________________________________________________________________

(Present Street Address) (City) (State) (Zip) (County)

____________________________________________________________________________________

(Permanent Street Address) (City) (State) (Zip) (County)

2. Preferred mailing address for ALL information: _____Present _____Permanent

3. Telephone number (day): ( ) _________________ Email address:_____________________________

4. Age:____________ Date of Birth:_____/______/______ Place of Birth:__________________

5. Are you a citizen of the United States of America? _____Yes _____No

6. Social Security Number: _______-_______-_______

7. Are you (check one): _____Single _____Married _____Divorced

8. Have you ever been known by another name? _____Yes _____No

If yes, state in full every other name by which you have been known: (If change was made by a Court

order, enclose a certified copy of such order)_______________________________________________

A photograph of you, not less

than 2x2 (snapshot not

acceptable) taken not more

than six months prior to the

date of application, must be

securely glued (NOT

STAPLED) to this space and

must NOT be larger than the

space provided. A passport

photograph is acceptable.

9. Please list all addresses for the past 10 years (Attach a separate sheet if necessary):

CITY STATE DATES RESIDED

10. Name two individuals who will always know your address:

Name:__________________________________ Name:___________________________________

Address:________________________________ Address:__________________________________

_______________________________________ _________________________________________

Phone:( )_____________________________ Phone:( )_______________________________

11. Have you ever declared bankruptcy? _____Yes _____No

If yes, please explain: (Attach a separate sheet if necessary):___________________________________

____________________________________________________________________________________

12. Please list any current and past drivers licenses you have maintained:

(DL#, if known)________________(State)_________(Dates Maintained)_____________________

13. a) Have you previously applied for the dental hygiene examination given in North Carolina?

_____Yes _____No If yes, give date(s):_______________________________________

b) Have you previously applied for a dental hygiene provisional license in North Carolina?

_____Yes _____No If yes, please provide date(s):_______________________________

c) Have you failed an examination given by North Carolina or another Board? _____Yes _____No

If yes, please give Board(s) and date(s):_____________________________________________

d) Have you ever been refused any examination given by North Carolina or another Board?

_____Yes _____No If yes, give Board(s) and date(s):_____________________________

e) Have you taken the Dental Hygiene National Board Exam? _____Yes _____No _____Pending

f) Have you ever failed the Dental Hygiene National Board Examination: _____Yes _____No

If yes, please list date(s):__________________________________________________________

g) Have you ever taken the CITA Examination:______Yes ______No ______Pending

If yes or pending, please list date for each portion:

Part I (if applicable): _________________ Part II: _________________

h) Have you ever failed a portion of the CITA Examination: ______Yes ______No

If yes, please list date(s):_________________________________________________________

14. Please list all jobs held within the past 10 years and, if terminated or asked to leave from that position,

please explain. (Attach a separate sheet if necessary.)

OCCUPATION EMPLOYER

W/ADDRESS & PHONE

DATE OF

EMPLOYMENT

REASON FOR

LEAVING

15. I am currently or have been licensed to practice dental hygiene in the following jurisdictions(Attach a

separate sheet if necessary): (RECENT GRADUATES GO TO #18.)

Jurisdiction

(State/Province/Territory)

How Licensed

(Exam, Reciprocity)

License/Permit

Number

Date of Issuance Years of Practice

16. I have practiced dental hygiene as follows: (Attach a separate sheet if necessary)

FROM TO NAME AND ADDRESS OF EMPLOYER REASON FOR LEAVING

17. As a dental hygienist, a member of any professional or other organization, or as a holder of any public

office:

a) Have you been suspended or otherwise disqualified or have a pending appeal of a determination

of suspension or disqualification? _____Yes _____No

b) Have you been reprimanded, censured or otherwise disciplined, or have a pending appeal of a

reprimand, censure or other disciplinary action? _____Yes _____No

c) Have any charges or complaints, formal or informal, been made or filed against you, or have any

proceedings been instituted against you? _____Yes _____No

d) Have you ever been reported to the National Practitioner Data Bank or the HIPPA (Health Care

Integrity and Protection) Data Bank? _____Yes _____No

If your answer is yes to any of the foregoing questions, for each occurrence furnish a written

statement giving the complete facts and state as to each case the date, the nature of the charge, the

disposition of the matter, and the name and address of the authority in possession of the records.

18. Have you been dropped, suspended, expelled, or disciplined by any school or college for any cause

whatsoever? _____Yes _____No

If yes, please list on a separate sheet of paper the date, school and nature of cause.

19. Have you ever been denied admission to any college or school for cause that reflects adversely on your

character? _____Yes _____No

20. Have you ever served in the armed forces of the United States or any other country? _____Yes _____No

If yes:

a) Have you been separated from such services? _____Yes _____No

b) State nature of separation_________________________________________

c) If other than honorable, furnish a written statement specifying type thereof and circumstances

surrounding your release.

d) State inclusive dates of service_____________________________________

e) In the armed services, have any charges or complaints, formal or informal, been made or filed

against you, or have any proceedings ever been instituted against you, or have you ever been a

defendant in any court martial? _____Yes _____No

If yes, please attach a separate sheet of paper with the date an explanation of each incident.

f) Have you registered under the Selective Service Act of 1948? _____Yes _____No

21. Have you ever:

a) been summoned to court or before a magistrate for the violation of any law or ordinance or for

the commission of any felony or misdemeanor? ____Yes ____ No

b) been arrested for the violation of any law or ordinance or for the commission of any felony or

misdemeanor? ____Yes ____ No

c) been taken into custody for the violation of any law or ordinance or for the commission of any

felony or misdemeanor? ____Yes ____ No

d) been indicted for the violation of any law or ordinance or for the commission of any felony or

misdemeanor? ____Yes ____ No

e) been convicted or tried for the violation of any law or ordinance or for the commission of any

felony or misdemeanor? ____Yes ____ No

f) been charged with the violation of any law or ordinance or for the commission of any felony or

misdemeanor? ____Yes ____ No

g) pleaded guilty to the violation of any law or ordinance or for the commission of any felony or

misdemeanor? ____Yes ____ No

If your answer is “yes” to any of the foregoing questions, please complete the Criminal Background Form

included at the end of this application and return along with the pertinent court documents. Only traffic

violations unrelated to alcohol or drugs may be excluded from this answer.

22. Within the past five years, have you exhibited any conduct or behavior that could call into question your

ability to practice dental hygiene in a competent, ethical, and professional manner?

□ Yes □ No

If you answered yes, furnish a thorough explanation below:

Explanation:_________________________________________________________________________

____________________________________________________________________________________

________________________________________________

Relevant date(s): _________________________________________________

23. A. Do you currently have any condition or impairment (including, but not limited to, substance

abuse, alcohol abuse, or a mental, emotional, or nervous disorder or condition) that in any way affects

your ability to practice dental hygiene in a competent, ethical, and professional manner?

□ Yes □ No

B. If your answer to Question 23(A) is yes, are the limitations caused by your condition or

impairment reduced or ameliorated because you receive ongoing treatment or because you participate in

a monitoring or support program? □ Yes □ No

If your answer to Question 23(A) or (B) is yes, complete a separate release and summary form for

each service provider that has assessed or treated any such condition or impairment. Release and

summary forms are attached and may be duplicated as needed. As used in Question 23, “currently”

means recently enough that the condition or impairment could reasonably affect your ability to function

as a dental hygienist.

HIGH SCHOOL EDUCATION

NAME AND LOCATION OF SCHOOL ATTENDED PERIOD OF ATTENDANCE (i.e. Sept. 1990 to Sept. 1994)

Year

I graduated from__________________________________High School ______________, _________________

(Month) (Year)

COLLEGE OR UNIVERSITY EDUCATION OTHER THAN DENTAL HYGIENE

NAME AND LOCATION OF SCHOOL ATTENDED PERIOD OF ATTENDANCE (i.e. Sept. 1990 to Sept. 1994)

DENTAL HYGIENE EDUCATION

NAME AND LOCATION OF SCHOOL ATTENDED PERIOD OF ATTENDANCE (i.e. Sept. 1990 to Sept. 1994)

Year

I received the degree of __________________________from___________________________________on the

(College or University)

_______________________day of ___________________________________________.

(Date) (Month/Year)

**An official FINAL dental hygiene school transcript, which includes the graduation date, degree

received, school seal, and Registrar’s signature, must accompany this application in a sealed school

envelope or sent directly to the Board’s office by the School’s Registrar. In the event that you are a

current year graduate, you must make arrangements to have your dental hygiene school send final

transcripts, when available, to the office of the Board of Dental Examiners.

24. In addition to the foregoing, I add the following:

a) I solemnly declare upon my honor that if granted a license to practice dental hygiene in North Carolina,

I shall respectfully comply with all laws regulating the practice of dental hygiene in this State, and will

do my best to uphold and maintain the ethics of the profession.

b) I hereby give permission to the North Carolina State Board of Dental Examiners to secure additional

information concerning me or any statement in this application from any person or any source the Board

may desire. I further agree to submit to questions by the Board or any member or employee thereof, and

to substantiate my statements if desired by the Board.

In order to determine my suitability for a license to practice dental hygiene in North Carolina, I

understand that the North Carolina State Board of Dental Examiners must make a thorough investigation of my

personal records and employment history. It is in the public’s best interest that any and all relevant information

concerning my personal and employment history be disclosed to the above named agency. Therefore, I do

hereby request and authorize any former and present employers, educational institutions, doctors or other health

care professionals including mental health, alcohol treatment centers, hospitals or other repositories of medical

records, government agencies, criminal and civil courts, including any private law firms and or

certification/licensing boards or commissions, any other individual agency or firm to produce and provide true

copies of any and all information and documents, including but not limited to privileged or confidential

documents to the Board regarding myself.

Moreover, I hereby release the Board from any civil or criminal liability whatsoever for seeking such

requested information and for evaluating such information as it relates to my application and potential license. I

hereby release the issuing agency and its agents, both individually and collectively from any and all liability for

damages of whatever kind, which may at any time result because of compliance with this request.

I hereby expressly waive all provisions of law forbidding any physician or other person who has

attended or examined me, or who may hereafter attend or examine me, from disclosing any knowledge or

information which he thereby acquired; and I hereby consent that he may disclose such knowledge or

information to the North Carolina State Board of Dental Examiners.

I further waive all rights to inspect or review any and all information compiled in reference to any

investigation or application for license. I do further hereby authorize the Board, its agents and employees, to

release true copies of any and all information to any agency or entity regulating the licensing authority of the

practice of dental hygiene.

I hereby acknowledge that this authorization is truly voluntary and is valid for one (1) year or until the

application and/or investigation process has been completed. A true copy of this document is considered valid,

just as the original.

I understand that this application is a continuing application and that I must provide full and correct

answers to the questions herein. I will notify the Board of any changes relating to any matter inquired about

herein.

I understand that failure to provide full and correct answers and/or failure to update my responses will

be grounds for denial of my application or revocation of my license.

I have read and fully understand the above statements.

_______________________________________________

(Signature)

_______________________________________________

(Print Name)

I,_________________________________________________, the applicant herein depose and say that

all facts, statements, and answers contained in this application are true and correct to the best of my knowledge.

I am not omitting any information which might be of value to this Board in determining my qualifications and

character, whether it is called for or not; and I agree that any falsification or withholding of information or facts

concerning my qualifications as an applicant shall be sufficient to bar me from this or any future examination

given by the North Carolina State Board of Dental Examiners, and such falsification or withholding shall serve

as sufficient grounds for the suspension or revocation of my North Carolina dental hygiene license even though

it is not discovered until after issuance.

________________________________________________

(Signature)

State/Territory/Jurisdiction of _____________________________

County/Province of____________________________

I______________________________________, a Notary Public for said County and

State/Territory/Jurisdiction, do hereby certify that__________________________________personally appeared

before me this the_______________day of_________________,_______________ and acknowledged the due

execution of the foregoing instrument.

Witness my hand and official seal, this the_____________day of______________________,________.

_______________________________________________

Notary Public

My commission expires:____________________ (SEAL)

NorthCarolinaLawnowrequiresthatallapplicantsandthoserenewingalicenserespondto

thefollowingstatement:



Public Notice Statement

required by N.C. Gen. Stat. § 143-764(a)(5), effective December 31,2017

Any worker who is defined as an employee by N.C. Gen. Stat. §§ 95-25.2(4)(NC

Department Of Labor), 143-762(a)(3)(Employee Fair Classification Act), 96-

1(b)(10)(Employment Security Act), 97-2(2)(Workers’ Compensation Act), or 105-

163.1(4)(Withholding; Estimated Income Tax for Individuals) shall be treated as an

employee unless the individual is an independent contractor. Any employee who

believes that the employee has been misclassified as an independent contractor by the

employee’s employer may report the suspected misclassification to the Employee

Classification Section within the North Carolina Industrial Commission.

Employee Classification Section

North Carolina Industrial Commission

1233 Mail Service Center

Raleigh, NC 27699-1233

Telephone: (919) 807-2582

Fax: (919)715-0282

Email: [email protected]

Employee misclassification is defined as avoiding tax liabilities and other obligations

imposed by Chapter 95, 96, 97, 105, or 143 of the North Carolina General Statutes by

misclassifying an employee as an independent contractor. [N.C. Gen. Stat. § 143-762(5)]

IcertifythatIhavereadandunderstandthePublicNoticeStatementfromtheNorthCarolina

IndustrialCommissionappearingaboveregardingtheclassificationofemployees.

____________Yes  _______________No

IfurthercertifythatI(______have)(______havenot)beeninvestigatedforemployee

misclassificationwithinthepastthree(3)years.



Ifyouhavebeeninvestigatedforemployeemisclassificationwithinthepastthreeyears,you

mustsubmittheresultsofthatinvestigationtotheNorthCarolinaStateBoardofDental

Examinersbeforeyourlicenserenewalwillbeconsideredcomplete.



DO NOT ALTER THIS FORM

Corrections/erasures VOID this form

Please use black or blue ink

To be used with Questions 22 and 23

AUTHORIZATION TO RELEASE MEDICAL INFORMATION FORM

By signing below, I authorize the above provider to provide information, without limitation, relating to mental illness or the

use of drugs and alcohol concerning advice, care, or treatment provided to me, to representatives of the Board of Dental

Examiners of the State of North Carolina who are involved in conducting an investigation into my moral character,

professional reputation, and fitness for the practice of law. I understand that any such information as may be received will

be reported only to the admitting authority. The information will be used or disclosed at my request. This authorization will

expire one year from the date of my notarized signature below. A photocopy of this form is acceptable for purposes of

obtaining this information.

I hereby release, discharge, and exonerate the Board of Dental Examiners of the State of North Carolina, its agents and

representatives, the admitting authority, its agents and representatives, and the above named provider, its agents and

representatives so furnishing information from any and all liability of every nature and kind arising out of the furnishing or

inspection of any documents, records, and other information, or out of the investigation made by the Board of Dental

Examiners of the State of North Carolina or by the admitting authority.

I am not required to sign this authorization in order to receive treatment from the above provider. I have the right to refuse

to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to

redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke

this authorization in writing except to the extent that the provider has acted in reliance upon this authorization. My written

revocation must be resubmitted to the Director of Investigations at the address of the provider above.

_________________________________________________________________

Signature of Applicant Date

STATE/DISTRICT OF _______________________________

COUNTY OF _______________________________

Subscribed and sworn to or affirmed before me this _______________day

of ______________, _______________

Month Year

_________________________________________________________________

Signature of Notary

My commission expires ______________________________________________

Seal or stamp must be affixed to each original.

The Board of Dental Examiners of the State of North Carolina is aware of HIPAA requirements.

Revised 08/08/2018

To be used with Question 22 or 23

DESCRIPTION OF CONDITION OR IMPAIRMENT FORM

Name __________________________________________________________________________________________

First Middle Last Suffix

Relevant dates: From Mo/Yr To Mo/Yr

Describe the condition or impairment

Describe any treatment, or any program that includes monitoring or support

Name and complete address of attending physician or counselor (if applicable):

Name of physician or counselor

Physician's or counselor's current address

City StateZip Country

Province

Telephone ( )

Name and complete address of hospital or institution (if applicable):

Name of hospital or institution

Hospital's or institution's current address

City StateZip Country

Province

Telephone ( )

The Board of Dental Examiners of the State of North Carolina is aware of HIPAA requirements.

STANDARD NCBLE Revised 9/4/2018